Sanford Individual TRUE $3,500

31195SD0080008
Silver
HMO

Sanford Individual TRUE $3,500 is a Silver HMO plan by Sanford Health Plan.

IMPORTANT: You are viewing the 2024 version of Sanford Individual TRUE $3,500 31195SD0080008. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Sanford Individual TRUE $3,500 is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Sanford Individual TRUE $3,500 31195SD0080008.
Insurer: Sanford Health Plan
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 31195SD0080008

Cost-Sharing Overview

Sanford Individual TRUE $3,500 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Sanford Individual TRUE $3,500?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Sanford Individual TRUE $3,500 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Sanford Individual TRUE $3,500 covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description: Emergency Only
Out of Service Area Coverage: No
Out of Service Area Coverage Description: Emergency or urgent care only with plan certification
National Network: No

Additional Benefits and Cost-Sharing

Sanford Individual TRUE $3,500 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$45.00 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$65.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$45.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Certain outpatient services may require authorization (pre-approval) by the Plan. For a list of services, see the Prior Authorization list at sanfordhealthplan.com.
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Hospice respite care limited to 15 inpatient and 15 outpatient days per lifetime. Hospice respite care must be used in increments of not more than 5 days at a time.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Testing for the diagnosis of infertility: Transvaginal ultrasound for structural evaluation (limit of 1 per calendar year) Sonogram (limit of 1 per calendar year) Screenings for stimulations of ovarian reserves and ovarian functions(limit of 1 per screening per calendar year) Screenings for assessment of polycystic ovarian syndrome (PCOS) (limit of 1 per calendar year) Semen Analysis (limit of 2 per calendar year)
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Nursing care that is provided to a Member on a one-to-one basis by licensed nurse in an inpatient or home setting. Prior authorization is required.
Routine Eye Exam (Adult)
Not Covered
Vision examination is only covered when related to injury, accident or cancer that damages the eye. Dilated eye examination for diabetes-related diagnosis (limit of one exam per Member per year)
Urgent Care Centers or Facilities
Covered
$60.00 Not Applicable$60.00 Not Applicable
Home Health Care Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Prior authorization is required.
Emergency Room Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Prior authorization is required.
Inpatient Physician and Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Surgery must be medically necessary. Not all procedures classified as weight reduction surgery are covered. Prior approval for weight reduction surgery is required.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%90.0 Days per Benefit Period Prior authorization is required. Limited to 90 days in any consecutive 12 month period.
Prenatal and Postnatal Care
Covered
No Charge Not ApplicableNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Deductible Amount is waived when the newborn is released with the mother.
Mental/Behavioral Health Outpatient Services
Covered
$45.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Prior authorization is required.
Substance Abuse Disorder Outpatient Services
Covered
$45.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Prior authorization is required.
Generic Drugs
Covered
$30.00 Not ApplicableNot Applicable 100.00% Covers up to a 30-day supply. Generic cost is based on total drug cost per 30-day supply. Brand name drugs with generic equivalents or biosimilar alternatives require additional cost share. Difference in cost does not apply to deductible or out-of-pocket limit. There are no limitations or restrictions for use of manufacturer coupons if used in conjunction with our current benefit offering. If the cost of the prescription falls under the copay amount, you will pay the least. Refer to your Formulary to determine which benefit applies to your medication.
Preferred Brand Drugs
Covered
$40.00 Not ApplicableNot Applicable 100.00% Covers up to a 30-day supply. Generic cost is based on total drug cost per 30-day supply. Brand name drugs with generic equivalents or biosimilar alternatives require additional cost share. Difference in cost does not apply to deductible or out-of-pocket limit. There are no limitations or restrictions for use of manufacturer coupons if used in conjunction with our current benefit offering. If the cost of the prescription falls under the copay amount, you will pay the least. Refer to your Formulary to determine which benefit applies to your medication.
Non-Preferred Brand Drugs
Covered
$150.00 Not ApplicableNot Applicable 100.00% Covers up to a 30-day supply. Generic cost is based on total drug cost per 30-day supply. Brand name drugs with generic equivalents or biosimilar alternatives require additional cost share. Difference in cost does not apply to deductible or out-of-pocket limit. There are no limitations or restrictions for use of manufacturer coupons if used in conjunction with our current benefit offering. If the cost of the prescription falls under the copay amount, you will pay the least. Refer to your Formulary to determine which benefit applies to your medication.
Specialty Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Preferred and Non-Preferred specialty drugs may be subject to different cost sharing rates. Covers up to a 30-day supply. Generic cost is based on total drug cost per 30-day supply. Brand name drugs with generic equivalents or biosimilar alternatives require additional cost share. Difference in cost does not apply to deductible or out-of-pocket limit. There are no limitations or restrictions for use of manufacturer coupons if used in conjunction with our current benefit offering. If the cost of the prescription falls under the copay amount, you will pay the least. Refer to your Formulary to determine which benefit applies to your medication.
Outpatient Rehabilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Habilitation Services
Covered
$45.00 Not ApplicableNot Applicable 100.00%
Chiropractic Care
Covered
$45.00 Not ApplicableNot Applicable 100.00%
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Prior authorization is required for certain items.
Hearing Aids
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per 3 Years When medically necessary for conditions including, but not limited to: sudden sensorineural hearing loss (SSNHL), accident, injury or related illness.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Prior authorization may be required.
Preventive Care/Screening/Immunization
Covered
No Charge Not ApplicableNot Applicable 100.00%
Routine Foot Care
Not Covered
Covered when medically appropriate.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Benefit Period Limited to 1 visit per calendar year. Benefit ends at the end of the month when the member turns 19.
Eye Glasses for Children
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Exam(s) per Benefit Period Limited to 1 frame every other year. Lenses or contact lenses limited to 1 item annually. Benefit ends at the end of the month when the member turns 19.
Dental Check-Up for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%2.0 Exam(s) per Benefit Period Limited to 2 routine check-up visits per calendar year. Preventive, emergency, and routine coverage available for members up to age 19. See your plan document for eligible services. Certain outpatient services may require authorization (pre-approval) by the plan. For a list of services, see the Prior Authorization list at sanfordhealthplan.com.
Rehabilitative Speech Therapy
Covered
$45.00 Not ApplicableNot Applicable 100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$45.00 Not ApplicableNot Applicable 100.00% Office visit copay covers evaluation.
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 100.00% Well Child Care to the Member’s 6th birthday, 100% of Allowed Charge.
Laboratory Outpatient and Professional Services
Covered
$45.00 Not ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
$45.00 Not ApplicableNot Applicable 100.00%
Basic Dental Care – Child
Covered
No Charge Not ApplicableNot Applicable 100.00% Limited to 2 routine check-up visits per calendar year. Preventive, emergency, and routine coverage available for members up to age 19. See your plan document for eligible services. Certain outpatient services may require authorization (pre-approval) by the plan. For a list of services, see the Prior Authorization list at sanfordhealthplan.com.
Orthodontia – Child
Covered
Not Applicable 50.00%Not Applicable 100.00%
Major Dental Care – Child
Covered
Not Applicable 50.00%Not Applicable 100.00%
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Elective abortion services are only covered when the mother?s life is endangered. Prior Authorization/certification required.
Transplant
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Prior authorization is required. To be eligible for coverage, Transplants must meet United Network for Organ Sharing (UNOS) criteria and/or Medical Criteria. Transplants must be performed at contracted Centers of Excellence or otherwise identified and accepted by Sanford Health Plan as qualified facilities.
Accidental Dental
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Oral surgical procedures limited to services required because of injury, accident or cancer that damages Natural Teeth. This is an Outpatient Surgery that requires Certification. Care must be received within twelve 12 months of the occurrence. Injury does not include injuries to Natural Teeth caused by biting or chewing. Associated radiology services are included. Coverage applies regardless of whether the services are provided in a Hospital or a dental office. Extractions when medically necessary because of injury, accident, or cancer when internal guidelines are met
Dialysis
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Plan will pay first for the first 30 months after you become eligible to join Medicare.
Allergy Testing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Benefit includes serum, injections, testing and treatment
Chemotherapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Prior authorization is required.
Radiation
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Prior authorization is required.
Diabetes Education
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%8.0 Visit(s) per Benefit Period
Prosthetic Devices
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Prosthetic limbs, sockets and supplies, and prosthetic eyes; Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy. Includes two (2) external prosthesis per Calendar Year and six (6) bras per Calendar Year. For double mastectomy: coverage extends to four (4) external prosthesis per Calendar Year and six (6) bras per Calendar Year. Devices permanently implanted that are not Experimental or Investigational Services such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy. Cranial Prosthesis, including wigs (limited to 1 per benefit period)Prosthetic limbs, sockets and supplies, and prosthetic eyes. Requires Prior Authorization.
Infusion Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Services for the Treatment and Diagnosis of TMJ/TMD are covered subject to Medical Necessity Manual therapy and osteopathic or chiropractic manipulation treatment if performed by physical medicine Providers TMJ Splints and adjustments if your primary diagnosis is TMJ/TMD Maximum Benefit Allowance of 1 splint per Member per Benefit Period
Nutritional Counseling
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%12.0 Visit(s) per Benefit Period
Reconstructive Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Some services require prior authorization.
Gender Affirming Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Prior Authorization requried

Free Preventive Services

There is no copayment or coinsurance for any of the following Sanford Individual TRUE $3,500 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Sanford Individual TRUE $3,500 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Sanford Individual TRUE $3,500?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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