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Blue Medicare Advantage PPO | Avera (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Medicare Advantage PPO | Avera (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Medicare Advantage PPO | Avera (PPO) in 2025, please refer to our full plan details page.
Blue Medicare Advantage PPO | Avera (PPO) is a PPO plan offered by Blue Cross Blue Shield of Michigan Mutual Ins. Co. available for enrollment in 2025 to people living in South Dakota. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Blue Medicare Advantage PPO | Avera (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Blue Medicare Advantage PPO | Avera (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Blue Medicare Advantage PPO | Avera (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $9000.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $9000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Blue Medicare Advantage PPO | Avera (PPO) plan has an enhanced alternative drug benefit. There is no deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. For example, standard generic drugs have a $10 copay, while preferred brand drugs have a 50% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for your Part D covered drugs.
Additional Benefits
The Blue Medicare Advantage PPO plan from Avera offers a range of benefits, including inpatient and outpatient hospital services, with varying copays depending on the specific service. Emergency services, primary care, preventive services, and hearing, vision, and dental services are also covered, with specific copays or coinsurance amounts outlined for each. The plan also includes benefits for home health services, dialysis, medical equipment, and diagnostic services.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For the lowest-tier service, the copay for a Medicare-covered stay is $500. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay for Inpatient Hospital-Acute and Upgrades for Inpatient Hospital-Acute are not covered. Additional Days for Inpatient Hospital Psychiatric and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $500, observation services with a copay between $325 and $650, ambulatory surgical center services with no copay, individual and group sessions for outpatient substance abuse with a copay between $30 and $60, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under this plan, but requires prior authorization. You will have to pay a copay between $60 and $80 for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Blue Medicare Advantage PPO plan. Ground and Air Ambulance Services have a $350 copay, with no coinsurance, while Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. For Emergency Services, there is a $125 copay, and for Urgently Needed Services, there is a $50 copay. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $120 copay, and Worldwide Emergency Transportation has a $350 copay.
Primary Care See details
Primary Care includes coverage for Primary Care Physician Services with a copay between $0 and $15, Chiropractic Services with a $20 copay, Occupational Therapy Services with a copay between $15 and $45, Physician Specialist Services with a copay between $30 and $60, Mental Health Specialty Services with a copay between $30 and $60 for individual and group sessions, Other Health Care Professional services with a copay between $0 and $60, Psychiatric Services with a copay between $30 and $60 for individual and group sessions, Physical Therapy and Speech-Language Pathology Services with a copay between $15 and $60, Additional Telehealth Benefits with a copay between $0 and $60, and Opioid Treatment Program Services with no copay; podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for annual physical exams with no copay, and additional preventive services with a copay for certain services, including Fitness Benefit, Remote Access Technologies, and Personal Emergency Response System (PERS). Other services like Health Education, In-Home Safety Assessment, Medical Nutrition Therapy, and others are not covered. Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered with no copay.
Hearing Services See details
Hearing Services include hearing exams with no copay, and prescription hearing aids with a $500 maximum benefit per year, per ear. OTC hearing aids are covered up to $50 per ear every three months.
Vision Services See details
Vision Services includes eye exams with a copay of $0-$60, and covers one routine eye exam every year. The plan covers contact lenses (1 pair per year) with a maximum benefit coverage amount of $100.00, and covers eyeglass lenses (1 pair per year) and eyeglass frames (1 frame per year) with a maximum benefit coverage amount of $100.00.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a copay of $30-$60, and Other Dental Services with a copay of $15. The plan also covers Oral Exams, Dental X-Rays, Prophylaxis (Cleaning), Endodontics with 50% coinsurance, Periodontics with 0-50% coinsurance, Prosthodontics (removable) with 50% coinsurance, Implant Services with 50% coinsurance, Prosthodontics (fixed) with 50% coinsurance, and Oral and Maxillofacial Surgery with 0-50% coinsurance; however, Fluoride Treatment, Maxillofacial Prosthetics, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Blue Medicare Advantage PPO | Avera (PPO) plan, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered, with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Blue Medicare Advantage PPO | Avera (PPO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance of 0% to 30%, Prosthetics/Medical Supplies with a coinsurance of 20% to 30%, and Diabetic Equipment with a coinsurance of 0% to 30%. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with copays and coinsurance depending on the specific service. Diagnostic Procedures/Tests have a copay between $30 and $60, Lab Services have a $5 copay, and Outpatient X-Ray Services have a $10 copay. Diagnostic Radiological Services have a copay between $90 and $180, while Therapeutic Radiological Services have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but specific services like Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD Services are not covered. The plan has a copay for Cardiac Rehabilitation Services, with details available.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, with prior authorization required. You will have no copay for days 1-20, and a $214 copay per day for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) items, with a maximum benefit coverage amount of $50.00 every three months, and Meal Benefits with no copay. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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