Individual & Family Plan 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

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, fill out forms and submit them to us.

Set-up an automatic bank withdrawal for your monthly premium payment (pdf)
Authorize a new person to access your health information (pdf)
Update or cancel your policy (pdf) for off-exchange plans only
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)
Request mail-order prescriptions (pdf)
Submit a member appeal (pdf)
Submit a member complaint (pdf)
Cost estimate request (pdf)

See All Forms

What Coverage Includes

Learn how to navigate health care, understand your coverage, get details on pharmacy benefits and more.

Coverage Pharmacy Benefits COVID-19 Coverage

Need to Pay Your Premium?

Check out convenient online and auto pay options – plus more ways to pay your monthly insurance premium.

Payment Options

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?

We have more tools ready at your fingertips. Get answers to common questions, find forms for updating your plan and much more. Just visit our Member Resources.

Member Resources Member Portal

Or contact our Customer Care 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?

Update Your Health Coverage

What Coverage Includes

Need to Pay Your Premium?

Popular with Members

Coverage Questions

Pharmacy Benefits

Well-Being Program

Flex & Health Savings Account

Member App

Virtual Visits

Member Forms

Health Insurance Glossary