Avera Health Plan - Eastern and Central South Dakota

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General Information

Plan Name:	Avera Health Plan
Service Area:	Eastern and Central South Dakota
Brochure:	PDF Version
Brochure:	Text Version
NCQA Accreditation:	No
JCAHO Accreditation:	No
URAC Accreditation:	No
Plan Type:	HMO
Enrollment Code-Self:	AV1
Enrollment Code-Self & Family:	AV2
Link to Plan Home Page:	http://www.averahealthplans.com
Telephone:	888/322-2115

Benefits

Doctor Care/ Primary Office Visits:	$10
Hospital Inpatient Room and Board Charges:	$250
RX/ Generic/ Retail:	$10
RX/ Brand/ Retail:	$20
RX/ Brand/ NonFormulary:	$35

Rates

Non-Postal
___Biweekly	Self: $26.30	Self: & Family: $60.36
___Twice Biweekly	Self: $52.60	Self: & Family: $120.72
___Monthly	Self: $56.98	Self: & Family: $130.78
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Annuitants
___Monthly	Self: $56.98	Self: & Family: $130.78
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U.S. Postal Service Employees (Type A)
___Monthly	Self: $25.64	Self: & Family: $58.85
___Biweekly	Self: $11.83	Self: & Family: $27.16
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U.S. Postal Service Employees (Type B)
___Monthly	Self: $25.64	Self: & Family: $58.85
___Biweekly	Self: $11.83	Self: & Family: $27.16
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Worker's Compensation Recipients
___Twice Biweekly	Self: $52.60	Self: & Family: $120.72
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Certain Temporary Employees
___Biweekly	Self: $105.20	Self: & Family: $241.44
___Monthly	Self: $227.93	Self: & Family: $523.12
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Former Spouse Enrollees
___Biweekly	Self: $105.20	Self: & Family: $241.44
___Monthly	Self: $227.93	Self: & Family: $523.12
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Temporary Continuation of Coverage
___Biweekly	Self: $107.30	Self: & Family: $246.27
___Monthly	Self: $232.49	Self: & Family: $533.58
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FDIC
___Biweekly	Self: $11.83	Self: & Family: $27.16
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