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Blue Medicare Advantage PPO | Avera (PPO) - H5900-005-000
$0.00
Monthly Premium
Blue Medicare Advantage PPO | Avera (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aware Integrated, Inc.
Plan ID: H5900-005-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
South Dakota Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about South Dakota Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $3,855.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $8,000.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $30.00 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $20.00 to $40.00 |
| Inpatient hospital care | Out-of-Network: Copayment for Acute Hospital Services per Stay $1500.00 |
| Urgent care | Urgent Care: Copayment for Urgent Care $50.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $120.00 Maximum Plan Benefit of $50000.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $100.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120.00 Copayment for Worldwide Emergency Transportation $120.00 Maximum Plan Benefit of $50000.00 |
| Ambulance transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $275.00 Copayment for Medicare Covered Ambulance Services - Air $275.00 |
Health Care Services and Medical Supplies
Blue Medicare Advantage PPO | Avera (PPO) covers a range of additional benefits. Learn more about Blue Medicare Advantage PPO | Avera (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $20.00 Copayment for Routine Care $30.00
|
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Coinsurance for Medicare-covered Diabetic Supplies 20.00% to 30.00% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20.00% to 30.00% |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 0.00% to 30.00% Prior Authorization Required for Durable Medical Equipment |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $30.00 to $200.00 Copayment for Medicare Covered Lab Services $30.00 Copayment for Medicare Covered Diagnostic Radiological Services $30.00 to $270.00 Coinsurance for Medicare Covered Therapeutic Radiological Services 20.00% Copayment for Medicare Covered Outpatient X-Ray Services $30.00 |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Please see Evidence of Coverage for Additional Home Health Benefits |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services - Tier 1: Copayment for Psychiatric Hospital Services - Tier 1 per Stay $375.00 Psychiatric Hospital Services - Tier 2: Copayment for Psychiatric Hospital Services - Tier 2 per Stay $750.00 |
| Mental health outpatient care | Out-of-Network: Outpatient Mental Health Services: Copayment for Medicare Covered Individual Sessions $60.00 Copayment for Medicare Covered Group Sessions $60.00 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $400.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $300.00 Prior Authorization Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual or Group Sessions $60.00 |
| Over-the-counter items | Out-of-Network: Over-The-Counter (OTC) Items: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $50.00 |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $25.00 to $45.00 |
| Skilled Nursing Facility (SNF) care | Out-of-Network: $0.00 per day for days 1 to 20 $190.00 per day for days 21 to 55 $0.00 per day for days 56 to 100 |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $60.00 Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $15.00 Coinsurance for Non-Medicare Covered Comprehensive Dental 0.00% to 50.00% |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $40.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00
|
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $30.00 to $60.00 Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $0.00 Copayment for Non-Medicare Covered Hearing Aids $0.00 |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
When reviewing South Dakota Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of South Dakota that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
South Dakota Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.