Employer-Provided Insurance Members

Network Provider FAQ

You always have the option to use any provider, but it’s important to know how choices can impact your health care costs.

What’s an in-network provider?

To help manage health care costs, you can get discounts on services and medical procedures when you receive care from Avera Health Plans in-network providers. These include physicians, hospitals, facilities and other health care providers participating in the our network.

These in-network benefits are available with more than 2,000 primary care physicians and 4,300 specialists and other health care providers available in your region.

What’s an out-of-network provider?

Out-of-network providers are physicians, hospitals and health care providers not participating in the Avera Health Plans network. If you receive medical care from an out-of-network provider, you’ll pay more for those services. Because this balance will not go toward your in-network deductible, you’ll pay more overall throughout the year.

Want to see in-network providers for your plan?

Log into Portal

Virta, Your Virtual Diabetes Clinic

A new path to effective weight loss is here. Avera Health Plans covers the cost of Virta, a diabetes support program, for eligible members between the ages 18 to 79 with type 2 diabetes.¹ Virta health coaches and dietitians work with you and qualifying dependents to understand individual goals, and then create a personalized plan to succeed.

Take the first step on your journey to better health today! Virta members lost 18 pounds on average in 10 weeks, and 87% of members were able to stop or reduce medications.²

Get Started

Update Your Health Coverage

We get it. Change happens. It’s important to let us know when you need to make updates to your plan. You can download and fill out forms. Be sure to ask your employer to review and sign off on the following form(s) before submitting to Avera Health Plans.

Authorize a new person to access your health information (pdf)
Coordinate benefits (pdf) if you have multiple health insurance carriers
Add an out-of-area residence (pdf) for your dependent(s)
Submit a prescription reimbursement claim (pdf)
Submit a member appeal (pdf)
Submit a member complaint (pdf)

See All Forms

1 Virta is available to Avera Health Plans members and eligible dependents between the ages of 18 and 79 who are enrolled in an eligible health plan. This benefit is currently being offered to those with type 2 diabetes. There are some medical conditions that would exclude patients from the Virta treatment. Start the application process now to find out if you qualify.

2 McKenzie AL, Hallberg SJ, Creighton BC, Volk BM, Link TM, Abner MK, Glon RM, McCarter JP, Volek JS, Phinney SD. A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes. JMIR Diabetes.

What Coverage Includes

Discover the information you need to make educated health care decisions, maximize your coverage, control your health care costs and be inspired to live a healthier life.

Coverage Pharmacy Benefits COVID-19 Coverage

Did you know? Depending on your specific plan's benefits, you may be able to take advantage of value-added services. To learn more about which value-added services are available to you, talk with your employer. These services may include:

COBRA benefits
Employee Assistance Program (EAP)
Flexible Spending Account (FSA)
Health Savings Account (HSA)
My Recovery Chemical Dependency Treatment Program
Diabetes Prevention Program
Tobacco Cessation Program
Fitness membership

Popular with Members

Check out our Member Guide (pdf) and these resources:

What's in the Member Portal?

The member portal – online and the app – are your go-to locations for details about your insurance policy, coverage, claims and more. Here are just some of the things you can find in the member portal:

Summary of Benefits

Review the Summary of Benefits and Coverage to learn about co-pays and other charges you’re responsible for – as well as pharmacy tier levels and benefit restrictions for out-of-network services.

Certificate of Coverage

Access the Certificate (Evidence) of Coverage or Individual Insurance Policy for details on:

Included and excluded benefits and services
Pharmacy benefits and management procedures
How to submit a claim for covered services
How to obtain services for primary care, specialty care, behavioral health care and hospital services
How to get care when you live out-of-network
How to submit a complaint
And more!

Additional Portal Features

Process claims and see explanation of benefits (EOBs).
Learn about pharmacy benefits including checking drug costs, viewing your prescription history, tracking your drug spend and more.
View the provider directory for your specific plan.
See if your plan includes wellness benefits including fitness discounts.
Learn about our well-being portal.

New Here?

Welcome! See what to expect as you become a new member and what to do once your policy application is approved.

New Members

Member ID Cards

You and each of your covered dependents (spouse and/or children) will receive a member identification (ID) card. Here’s what you need to know about your card, when you’ll get your first one and how to get a replacement.

Learn More

Your Trusted Partners in Health

Connecting you to health topics that interest you, learn about health plans and find guidance to stay healthy.

Need Something Else?

See all of our member resources online.

Member Resources Member Portal

Or contact our Customer Service team.

Search Avera Health Plans

Network Provider FAQ

What’s an in-network provider?

What’s an out-of-network provider?

Want to see in-network providers for your plan?

Virta, Your Virtual Diabetes Clinic

Update Your Health Coverage

What Coverage Includes

Popular with Members

Coverage Questions

Pharmacy Benefits

Well-Being Program

Flex & Health Savings Account

Member App

Virtual Visits

Member Forms

Health Insurance Glossary