Sanford Individual TRUE $7,100 HSA Qualified
89364ND0090009
Expanded Bronze
HMO
Sanford Individual TRUE $7,100 HSA Qualified is an Expanded Bronze HMO plan by Sanford Health Plan.
Locations
Sanford Individual TRUE $7,100 HSA Qualified is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of Sanford Individual TRUE $7,100 HSA Qualified 89364ND0090009.
| Insurer: | Sanford Health Plan |
| Network Type: | HMO |
| Metal Type: | Expanded Bronze |
| HSA Eligible?: | Yes |
| Plan ID: | 89364ND0090009 |
Cost-Sharing Overview
Sanford Individual TRUE $7,100 HSA Qualified offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Sanford Individual TRUE $7,100 HSA Qualified includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $7100 per person | $14200 per group |
| Deductible: | $7100 per person | $14200 per group |
| Coinsurance: | 0.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Sanford Individual TRUE $7,100 HSA Qualified will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $7,100 |
| Copayment: | $0 |
| Coinsurance: | $0 |
| Limit: | $60 |
| Deductible: | $5,000 |
| Copayment: | $0 |
| Coinsurance: | $0 |
| Limit: | $20 |
| Deductible: | $2,800 |
| Copayment: | $0 |
| Coinsurance: | $0 |
| Limit: | $0 |
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 $7,100 HSA Qualified?
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 $7,100 HSA Qualified 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 $7,100 HSA Qualified covers when you are out of the service area or out of the country.
| Out of Country Coverage: | No |
| Out of Country Coverage Description: | Only in Emergent Medical situations |
| Out of Service Area Coverage: | No |
| Out of Service Area Coverage Description: | Only in Emergent Medical situations |
| National Network: | No |
Additional Benefits and Cost-Sharing
Sanford Individual TRUE $7,100 HSA Qualified 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 | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Specialist Visit Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Hospice Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| 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 No Charge after deductible | Not 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 | Not Applicable No Charge after deductible | Not Applicable 20.00% Coinsurance after deductible | |
| Home Health Care Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 40.0 Visit(s) per Benefit Period Prior authorization is required in lieu of a Hospital or Skilled Nursing Facility stay. |
| Emergency Room Services Covered | Not Applicable No Charge after deductible | Not Applicable No Charge after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable No Charge after deductible | Not Applicable No Charge after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Prior authorization is required. |
| Inpatient Physician and Surgical Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Bariatric Surgery Covered | Not Applicable No Charge after deductible | Not 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 No Charge after deductible | Not Applicable 100.00% | 30.0 Days per Benefit Period Preauthorization is required. |
| Prenatal and Postnatal Care Covered | No Charge Not Applicable | Not Applicable 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Mental/Behavioral Health Outpatient Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Prior authorization is required. |
| Substance Abuse Disorder Outpatient Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | For SUD, PA required for inpatient, residential, partial hospitalization, and intensive outpatient. |
| Generic Drugs Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Drugs on the preventive medications list are not subject to a deductible. Some preventative drugs are subject to copayment/coinsurance or nothing at all. |
| Preferred Brand Drugs Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Non-Preferred Brand Drugs Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Specialty Drugs Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Preferred and Non-Preferred specialty drugs may be subject to different cost sharing rates. |
| Outpatient Rehabilitation Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 30.0 Visit(s) per Benefit Period |
| Habilitation Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 30.0 Visit(s) per Benefit Period |
| Chiropractic Care Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 20.0 Visit(s) per Benefit Period |
| Durable Medical Equipment Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Coverage for DME prescribed by an attending Practitioner and/or Provider, which is Medically Necessary, not primarily and customarily used for non-medical purposes, designed for prolonged use, and for a specific therapeutic purpose in the treatment of an illness or injury. Limitations per Sanford Health Plan policy guidelines apply. Casts, splints, braces, crutches and dressings for the treatment of fracture, dislocation, torn muscles or ligaments and other chronic conditions per Sanford Health Plan policy. Prior authorization is required for certain items. |
| Hearing Aids Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 1.0 Item(s) per 3 Years |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Prior authorization may be required. |
| Preventive Care/Screening/Immunization Covered | No Charge Not Applicable | Not 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 Applicable | Not Applicable 100.00% | 1.0 Exam(s) per Benefit Period |
| Eye Glasses for Children Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 1.0 Item(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 Applicable | Not Applicable 100.00% | 2.0 Exam(s) per Benefit Period |
| Rehabilitative Speech Therapy Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 30.0 Visit(s) per Year |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | 30.0 Visit(s) per Year |
| Well Baby Visits and Care Covered | No Charge Not Applicable | Not Applicable 100.00% | Well Child Care to the Member’s 6th birthday, 100% of Allowed Charges. |
| Laboratory Outpatient and Professional Services Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| X-rays and Diagnostic Imaging Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Basic Dental Care – Child Covered | No Charge Not Applicable | Not Applicable 100.00% | |
| Orthodontia – Child Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Major Dental Care – Child Covered | Not Applicable No Charge after deductible | 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 No Charge after deductible | Not 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 No Charge after deductible | Not 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 No Charge after deductible | Not Applicable 100.00% | Plan will pay first for the first 30 months after you become eligible to join Medicare. |
| Allergy Testing Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Benefit includes serum, injections, testing and treatment. |
| Chemotherapy Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Prior authorization is required. |
| Radiation Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Prior authorization is required. |
| Diabetes Education Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | |
| Prosthetic Devices Covered | Not Applicable No Charge after deductible | Not 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 No Charge after deductible | Not Applicable 100.00% | |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable No Charge after deductible | Not 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 No Charge after deductible | Not Applicable 100.00% | 12.0 Visit(s) per Benefit Period |
| Reconstructive Surgery Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Some services require prior authorization. |
| Gender Affirming Care Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Prior Authorization requried |
| Applied Behavior Analysis Based Therapies Covered | Not Applicable No Charge after deductible | Not Applicable 100.00% | Covered service for the treatment of Autism Spectrum Disorder. Prior Authorization required. |
Free Preventive Services
There is no copayment or coinsurance for any of the following Sanford Individual TRUE $7,100 HSA Qualified 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Sanford Individual TRUE $7,100 HSA Qualified 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 $7,100 HSA Qualified?
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