Blue Medicare Advantage PPO | Avera (PPO) is a Medicare Advantage (Part C) Plan by Wellmark Advantage Health Plan.
This page features plan details for 2023 Blue Medicare Advantage PPO | Avera (PPO) H5900 – 005 – 0 available in South Dakota.
Blue Medicare Advantage PPO | Avera (PPO) is offered in the following locations.
Blue Medicare Advantage PPO | Avera (PPO) offers the following coverage and cost-sharing.
Insurer: | Wellmark Advantage Health Plan |
Health Plan Deductible: | $0.00 |
MOOP: | $7,500 In and Out-of-network $3,755 In-network |
Drugs Covered: | Yes |
Ready to sign up for Blue Medicare Advantage PPO | Avera (PPO) ?
Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$164.90 | $0.00 | $0.00 | $0.00 | $164.90 |
Blue Medicare Advantage PPO | Avera (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Deductible: | $0.00 |
Initial Coverage Limit: | $4,660.00 |
Catastrophic Coverage Limit: | $7,400.00 |
Drug Benefit Type: | Enhanced |
Gap Coverage: | No |
Formulary Link: | Formulary Link |
Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
---|---|---|---|---|
$0.00 | $43.40 | $34.80 | $26.30 | $17.70 |
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $12.00 copay | $2.00 copay | |
2 (Generic) | $7.00 copay | $15.00 copay | $8.00 copay | |
3 (Preferred Brand) | $47.00 copay | $47.00 copay | $37.00 copay | |
4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | $100.00 copay | |
5 (Specialty Tier) | 33% | 33% | 33% |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | ||||
2 (Generic) | ||||
3 (Preferred Brand) | ||||
4 (Non-Preferred Drug) | ||||
5 (Specialty Tier) |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $34.00 copay | $0.00 copay | |
2 (Generic) | $21.00 copay | $45.00 copay | $0.00 copay | |
3 (Preferred Brand) | $109.00 copay | $139.00 copay | $111.00 copay | |
4 (Non-Preferred Drug) | $290.00 copay | $290.00 copay | $290.00 copay | |
5 (Specialty Tier) |
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
Tier | Cost |
---|---|
All other tiers (Generic) | 25% |
All other tiers (Brand-name) | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
Drug Type | Cost Share |
---|---|
Generic drugs | $4.15 copay or 5% (whichever costs more) |
Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Blue Medicare Advantage PPO | Avera (PPO) also provides the following benefits.
In-Network: Yes, contact plan for further details |
Diagnostic services: | Not covered (no limits) |
Endodontics: | Not covered (no limits) |
Extractions: | In-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Extractions: | Out-of-Network: 0-50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Non-routine services: | Not covered (no limits) |
Periodontics: | In-Network: 0-50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Periodontics: | Out-of-Network: 0-50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Prosthodontics, other oral/maxillofacial surgery, other services: | In-Network: 0-50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Prosthodontics, other oral/maxillofacial surgery, other services: | Out-of-Network: 0-50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Restorative services: | In-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Restorative services: | Out-of-Network: 0-50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Cleaning: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
Dental x-ray(s): | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
Fluoride treatment: | Not covered (no limits) |
Office visit: | In-Network: $25.00 (authorization not required) (referral not required) |
Office visit: | Out-of-Network: $25 copay (authorization not required) (referral not required) |
Oral exam: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
Diagnostic radiology services (e.g., MRI): | In-Network: $0-180 copay (authorization not required) (referral not required) |
Diagnostic radiology services (e.g., MRI): | Out-of-Network: $30-270 copay (authorization not required) (referral not required) |
Diagnostic tests and procedures: | In-Network: $0-100 copay (authorization not required) (referral not required) |
Diagnostic tests and procedures: | Out-of-Network: $30-270 copay (authorization not required) (referral not required) |
Lab services: | In-Network: $0-15 copay (authorization not required) (referral not required) |
Lab services: | Out-of-Network: $30 copay (authorization not required) (referral not required) |
Outpatient x-rays: | In-Network: $10-20 copay (authorization not required) (referral not required) |
Outpatient x-rays: | Out-of-Network: $30 copay (authorization not required) (referral not required) |
Primary: | In-Network: $0-15 copay per visit |
Primary: | Out-of-Network: $30 copay per visit |
Specialist: | In-Network: $20-40 copay per visit (authorization not required) (referral not required) |
Specialist: | Out-of-Network: $60 copay per visit (authorization not required) (referral not required) |
Emergency: | $90 copay per visit (always covered) |
Urgent care: | $40 copay per visit (always covered) |
Foot exams and treatment: | In-Network: $25-45 copay (authorization not required) (referral not required) |
Foot exams and treatment: | Out-of-Network: $60 copay (authorization not required) (referral not required) |
Routine foot care: | Not covered |
In-Network: $250 copay | |
Out-of-Network: $250 copay |
$0.00 |
In-Network: No |
Fitting/evaluation: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Fitting/evaluation: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Hearing aids: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Hearing aids: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Hearing exam: | In-Network: $0-40 copay (authorization not required) (referral not required) |
Hearing exam: | Out-of-Network: $0-60 copay (authorization not required) (referral not required) |
In-Network: Tier 1 $375 per stay Tier 2 $700 per stay (authorization required) (referral not required) | |
Out-of-Network: $1,500 per stay (authorization required) (referral not required) |
In-Network: $0-400 copay per visit (authorization required) (referral not required) | |
Out-of-Network: $45-600 copay per visit (authorization required) (referral not required) |
$7,500 In and Out-of-network $3,755 In-network |
Diabetes supplies: | In-Network: 0-30% coinsurance per item (authorization not required) |
Diabetes supplies: | Out-of-Network: 40% coinsurance per item (authorization not required) |
Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 0-30% coinsurance per item (authorization required) |
Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 40% coinsurance per item (authorization required) |
Prosthetics (e.g., braces, artificial limbs): | In-Network: 20-30% coinsurance per item (authorization not required) |
Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 40% coinsurance per item (authorization not required) |
Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
Chemotherapy: | Out-of-Network: 40% coinsurance (authorization required) |
Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
Other Part B drugs: | Out-of-Network: 40% coinsurance (authorization required) |
Inpatient hospital – psychiatric: | In-Network: Tier 1 $375 per stay Tier 2 $700 per stay (authorization not required) (referral not required) |
Inpatient hospital – psychiatric: | Out-of-Network: $1,500 per stay (authorization not required) (referral not required) |
Outpatient group therapy visit: | In-Network: $20-40 copay (authorization not required) (referral not required) |
Outpatient group therapy visit: | Out-of-Network: $60 copay (authorization not required) (referral not required) |
Outpatient group therapy visit with a psychiatrist: | In-Network: $20-40 copay (authorization not required) (referral not required) |
Outpatient group therapy visit with a psychiatrist: | Out-of-Network: $60 copay (authorization not required) (referral not required) |
Outpatient individual therapy visit: | In-Network: $20-40 copay (authorization not required) (referral not required) |
Outpatient individual therapy visit: | Out-of-Network: $60 copay (authorization not required) (referral not required) |
Outpatient individual therapy visit with a psychiatrist: | In-Network: $20-40 copay (authorization not required) (referral not required) |
Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: $60 copay (authorization not required) (referral not required) |
No |
In-Network: $0 copay (authorization not required) (referral not required) | |
Out-of-Network: $0 copay (authorization not required) (referral not required) |
Occupational therapy visit: | In-Network: $20-40 copay (authorization not required) (referral not required) |
Occupational therapy visit: | Out-of-Network: $60 copay (authorization not required) (referral not required) |
Physical therapy and speech and language therapy visit: | In-Network: $20-40 copay (authorization not required) (referral not required) |
Physical therapy and speech and language therapy visit: | Out-of-Network: $60 copay (authorization not required) (referral not required) |
In-Network: $0 per day for days 1 through 20 $187 per day for days 21 through 55 $0 per day for days 56 through 100 (authorization required) (referral not required) | |
Out-of-Network: $0 per day for days 1 through 20 $187 per day for days 21 through 55 $0 per day for days 56 through 100 (authorization required) (referral not required) |
Not covered |
Contact lenses: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Contact lenses: | Out-of-Network: 0-50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Eyeglass frames: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglass frames: | Out-of-Network: 0-50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Eyeglass lenses: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglass lenses: | Out-of-Network: 0-50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglasses (frames and lenses): | Out-of-Network: 0-50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Other: | Not covered (no limits) |
Routine eye exam: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
Routine eye exam: | Out-of-Network: 0-50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Upgrades: | Not covered |
Covered (authorization not required) (referral not required) |
Ready to sign up for Blue Medicare Advantage PPO | Avera (PPO) ?
SMID: MULTIPLAN_HCIHNDOGMED01_M
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