Avera Standard $1500
60536SD0020051
Gold
PPO
Avera Standard $1500 is a Gold PPO plan by Avera Health Plans.
IMPORTANT: You are viewing the 2024 version of Avera Standard $1500 60536SD0020051. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.
Locations
Avera Standard $1500 is offered in the following counties.
Plan Overview
This is a plan overview for 2024 version of Avera Standard $1500 60536SD0020051.
| Insurer: | Avera Health Plans |
| Network Type: | PPO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 60536SD0020051 |
Cost-Sharing Overview
Avera Standard $1500 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Avera Standard $1500 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8700 per person | $17400 per group |
| Deductible: | $1500 per person | $3000 per group |
| Coinsurance: | 25.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Avera Standard $1500 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | $10000 per person | $20000 per group |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $1,500.00 |
| Copayment: | $10.00 |
| Coinsurance: | $2,800.00 |
| Limit: | $60.00 |
| Deductible: | $900.00 |
| Copayment: | $900.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $1,500.00 |
| Copayment: | $300.00 |
| Coinsurance: | $100.00 |
| Limit: | $0.00 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Avera Standard $1500?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
Avera Standard $1500 offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | Abortion (except when the life of the mother is endangered), acupuncture, cosmetic surgery, dental care for adults, hearing aids, infertility treatment, long-term care, non-emergency care when traveling outside the United States, routine eye care for adults, and weight loss programs. |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Avera Standard $1500 covers when you are out of the service area or out of the country.
| Out of Country Coverage: | No |
| Out of Country Coverage Description: | |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | Emergency or urgent care services are covered if traveling outside of our service area. No coverage for health services if you travel outside our service area for the purpose of seeking medical treatment. |
| National Network: | Yes |
Additional Benefits and Cost-Sharing
Avera Standard $1500 includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | $30.00 Not Applicable | Not Applicable 35.00% Coinsurance after deductible | |
| Specialist Visit Covered | $60.00 Not Applicable | Not Applicable 35.00% Coinsurance after deductible | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $30.00 Not Applicable | Not Applicable 35.00% Coinsurance after deductible | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Hospice Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | 185.0 Days per Year |
| Routine Dental Services (Adult) | |||
| Infertility Treatment | |||
| Long-Term/Custodial Nursing Home Care | |||
| Private-Duty Nursing Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Routine Eye Exam (Adult) | |||
| Urgent Care Centers or Facilities Covered | $45.00 Not Applicable | Not Applicable 35.00% Coinsurance after deductible | In-network benefit for services outside of service area. When using Out-of-Network Provider inside service area you may contact the plan to determine if your visit qualifies for in-network benefits. |
| Home Health Care Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | 60-visit limit per plan year for services from non-participating providers. One visit equals a maximum of 4 hours, including private duty nursing. |
| Emergency Room Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 25.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 25.00% Coinsurance after deductible | Preauthorization for non-emergency transportation. No coverage for services without preauthorization. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | Preauthorization required. No coverage for services without preauthorization |
| Inpatient Physician and Surgical Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | Preauthorization required. No coverage for services without preauthorization |
| Bariatric Surgery Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | 1.0 Procedure(s) per Lifetime Preauthorization required. No coverage for services without preauthorization |
| Cosmetic Surgery | |||
| Skilled Nursing Facility Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | 100.0 Days per Admission 100-day confinement limit is for services from participating providers. 60-day confinement limit for services from non-participating providers. Same confinement limit if readmitted with same diagnosis within 60 days. |
| Prenatal and Postnatal Care Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). |
| Mental/Behavioral Health Outpatient Services Covered | $30.00 Not Applicable | Not Applicable 35.00% Coinsurance after deductible | Coinsurance will apply for services other than therapy performed in the office or any service at a facility. |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | Preauthorization required. No coverage for services without preauthorization. |
| Substance Abuse Disorder Outpatient Services Covered | $30.00 Not Applicable | Not Applicable 35.00% Coinsurance after deductible | Coinsurance will apply for services other than therapy performed in the office or any service at a facility. |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Generic Drugs Covered | $15.00 Not Applicable | Not Applicable 100.00% | Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered. |
| Preferred Brand Drugs Covered | $30.00 Not Applicable | Not Applicable 100.00% | Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered. |
| Non-Preferred Brand Drugs Covered | $60.00 Not Applicable | Not Applicable 100.00% | Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered. |
| Specialty Drugs Covered | $250.00 Not Applicable | Not Applicable 100.00% | Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered. |
| Outpatient Rehabilitation Services Covered | $30.00 Not Applicable | Not Applicable 35.00% Coinsurance after deductible | Cardiac and pulmonary rehab services from participating providers are coinsurance after deductible and have a 36-visit maximum per plan year. |
| Habilitation Services Covered | $30.00 Not Applicable | Not Applicable 35.00% Coinsurance after deductible | Cardiac and pulmonary rehab services from participating providers are coinsurance after deductible and have a 36-visit maximum per plan year. |
| Chiropractic Care Covered | $30.00 Not Applicable | Not Applicable 100.00% | |
| Durable Medical Equipment Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | Certain durable medical equipment require preauthorization. No coverage for services without preauthorization. |
| Hearing Aids | |||
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | Some imaging requires preauthorization. Major lab and X-ray services may include PET scan, MRI, CT scan, SPECT scan, cardiovascular, nuclear medicine and MRA. |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 100.00% | Age and frequency limitations may apply |
| Routine Foot Care | |||
| Acupuncture | |||
| Weight Loss Programs | |||
| Routine Eye Exam for Children Covered | No Charge Not Applicable | Not Applicable 100.00% | 1.0 Visit(s) per Year One diagnostic exam per calendar year for children under the age of 19 from a VSP provider. |
| Eye Glasses for Children Covered | No Charge Not Applicable | Not Applicable 100.00% | 1.0 Item(s) per Year One frame from the designated pediatric eyewear collection are covered. |
| Dental Check-Up for Children Covered | No Charge Not Applicable | Not Applicable 100.00% | 1.0 Visit(s) per 6 Months |
| Rehabilitative Speech Therapy Covered | $30.00 Not Applicable | Not Applicable 35.00% Coinsurance after deductible | Cardiac and pulmonary rehab services from participating providers are coinsurance after deductible and have a 36-visit maximum per plan year. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $30.00 Not Applicable | Not Applicable 35.00% Coinsurance after deductible | Cardiac and pulmonary rehab services from participating providers are coinsurance after deductible and have a 36-visit maximum per plan year. |
| Well Baby Visits and Care Covered | No Charge Not Applicable | Not Applicable 100.00% | Age and frequency limitations may apply |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Basic Dental Care – Child Covered | No Charge Not Applicable | Not Applicable 100.00% | 1.0 Visit(s) per 6 Months |
| Orthodontia – Child Covered | Not Applicable 50.00% | Not Applicable 100.00% | Frequency limitations may apply |
| Major Dental Care – Child Covered | Not Applicable 50.00% | Not Applicable 100.00% | Frequency limitations may apply |
| Basic Dental Care – Adult | |||
| Orthodontia – Adult | |||
| Major Dental Care – Adult | |||
| Abortion for Which Public Funding is Prohibited | |||
| Transplant Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Accidental Dental Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Dialysis Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Allergy Testing Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Chemotherapy Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Radiation Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Diabetes Education Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | 8.0 Visit(s) per Year State law allows two education programs per lifetime and up to 8 follow-up visits per year |
| Prosthetic Devices Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Infusion Therapy Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Nutritional Counseling | |||
| Reconstructive Surgery Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Gender Affirming Care Not Covered |
Free Preventive Services
There is no copayment or coinsurance for any of the following Avera Standard $1500 preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Avera Standard $1500 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for Avera Standard $1500?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904