Sanford Simplicity – Standardized $5,800
31195SD0110017
Silver
PPO
Sanford Simplicity – Standardized $5,800 is a Silver PPO plan by Sanford Health Plan.
IMPORTANT: You are viewing the 2023 version of Sanford Simplicity – Standardized $5,800 31195SD0110017. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
Sanford Simplicity – Standardized $5,800 is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of Sanford Simplicity – Standardized $5,800 31195SD0110017.
| Insurer: | Sanford Health Plan |
| Network Type: | PPO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 31195SD0110017 |
Cost-Sharing Overview
Sanford Simplicity – Standardized $5,800 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Sanford Simplicity – Standardized $5,800 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8,900.00 | $8900 per person | $17800 per group |
| Deductible: | $5,800.00 | $5800 per person | $11600 per group |
| Coinsurance: | 40.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Sanford Simplicity – Standardized $5,800 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | $17,800.00 | $17800 per person | $35600 per group |
| Out-of-Network Deductible: | $11,600.00 | $11600 per person | $23200 per group |
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: | $5,800.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $60.00 |
| Deductible: | $100.00 |
| Copayment: | $1,400.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,100.00 |
| Copayment: | $400.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
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 Simplicity - Standardized $5,800?
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 Simplicity – Standardized $5,800 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 Simplicity – Standardized $5,800 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: | Yes |
| Out of Service Area Coverage Description: | Emergency or urgent care only with plan certification |
| National Network: | Yes |
Additional Benefits and Cost-Sharing
Sanford Simplicity – Standardized $5,800 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 | $40.00 | 60.00% Coinsurance after deductible | |
| Specialist Visit Covered | $80.00 | 60.00% Coinsurance after deductible | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $40.00 | 60.00% Coinsurance after deductible | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required |
| Outpatient Surgery Physician/Surgical Services Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | |
| Hospice Services Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 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 | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Nursing care that is provided to a Member on a one-to-one basis by licensed nurse in an inpatient or home setting |
| Routine Eye Exam (Adult) Not Covered | Vision examination is only covered when related to an illness or injury. | ||
| Urgent Care Centers or Facilities Covered | $60.00 | $60.00 | |
| Home Health Care Services Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization required. |
| Emergency Room Services Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required |
| Inpatient Physician and Surgical Services Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | |
| Bariatric Surgery Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 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 | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 90 Days per Year Preauthorization is required. |
| Prenatal and Postnatal Care Covered | No Charge | 60.00% Coinsurance after deductible | |
| Delivery and All Inpatient Services for Maternity Care Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Deductible Amount is waived when the newborn is released with the mother |
| Mental/Behavioral Health Outpatient Services Covered | $40.00 | 60.00% Coinsurance after deductible | Other outpatient services are subject to deductible/coinsurance. |
| Mental/Behavioral Health Inpatient Services Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | |
| Substance Abuse Disorder Outpatient Services Covered | $40.00 | 60.00% Coinsurance after deductible | Other outpatient services are subject to deductible/coinsurance. |
| Substance Abuse Disorder Inpatient Services Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | |
| Generic Drugs Covered | $20.00 | 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 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. |
| Preferred Brand Drugs Covered | $40.00 | 100.00% | |
| Non-Preferred Brand Drugs Covered | $80.00 Copay after deductible | 100.00% | |
| Specialty Drugs Covered | $350.00 Copay after deductible | 100.00% | |
| Outpatient Rehabilitation Services Covered | $40.00 | 60.00% Coinsurance after deductible | Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. Benefits are not available for Maintenance Care. Other outpatient services are subject to deductible/coinsurance. |
| Habilitation Services Covered | $40.00 | 60.00% Coinsurance after deductible | Treatment for Autism Spectrum Disorder (ASD) with speech therapy, occupational therapy, or physical therapy is covered. Use of Applied Behavioral Analysis (ABA) for the treatment of ASD is covered with the following minimum coverage limits: 1) through age 6: 1300 hours per benefit period; 2) ages 7-13: 900 hours per benefit period; 3) ages 14-18: 450 hours per benefit period. Other outpatient services are subject to deductible/coinsurance. |
| Chiropractic Care Covered | $40.00 | 60.00% Coinsurance after deductible | |
| Durable Medical Equipment Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Equipment must primarily and customarily serve a medical purpose. Issuer determines whether to pay the rental amount or the purchase price amount for an item and determine the length of any rental term. Prior authorization may be required. |
| Hearing Aids Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 1 Item(s) per 3 Years Must have hearing loss that is not corrected by other covered procedures. |
| Imaging (CT/PET Scans, MRIs) Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior authorization may be required |
| Preventive Care/Screening/Immunization Covered | 0.00% | 60.00% Coinsurance after deductible | |
| Routine Foot Care Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Covered when medically appropriate. |
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | No Charge | 60.00% Coinsurance after deductible | 1 Exam(s) per Year |
| Eye Glasses for Children Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 1 Item(s) per Year Limited to 1 frame every other year. |
| Dental Check-Up for Children Covered | No Charge | 60.00% Coinsurance after deductible | 2 Visit(s) per Year Certain dental services may require authorization (pre-approval) by the plan. |
| Rehabilitative Speech Therapy Covered | $40.00 | 60.00% Coinsurance after deductible | Coverage includes rehabilitative speech therapy services when related to a specific illness, injury, or impairment and involve the mechanics of phonation, articulation, or swallowing. Services must be provided by a licensed or certified speech pathologist. Other outpatient services are subject to deductible/coinsurance. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $40.00 | 60.00% Coinsurance after deductible | Occupational therapy is only covered insofar as services to treat the upper extremities, which means the arms from the shoulders to the fingers. Other outpatient services are subject to deductible/coinsurance. |
| Well Baby Visits and Care Covered | No Charge | 60.00% Coinsurance after deductible | Well Child Care to the Member’s 6th birthday, 100% of Allowed Charge. |
| Laboratory Outpatient and Professional Services Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | |
| X-rays and Diagnostic Imaging Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | |
| Basic Dental Care – Child Covered | No Charge | 60.00% Coinsurance after deductible | |
| Orthodontia – Child Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | |
| Major Dental Care – Child Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | |
| 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 | |||
| Transplant Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 1 Exam(s) per Transplant Transplants are subject to Case Management. |
| Accidental Dental Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 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 |
| Dialysis Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | |
| Allergy Testing Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Benefit includes serum, injections, testing and treatment |
| Chemotherapy Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | |
| Radiation Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | |
| Diabetes Education Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 8 Visit(s) per Benefit Period Quantity Limit: Two certified diabetes education programs per member per lifetime, and eight visits per benefit year for follow-up training once patient has participated in a diabetes education program. |
| Prosthetic Devices Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 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 up to $200 |
| Infusion Therapy Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Infusion therapy is covered when provided in the home (home infusion therapy). |
| Treatment for Temporomandibular Joint Disorders Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 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 | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | 12 Visit(s) per Benefit Period |
| Reconstructive Surgery Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | |
| Gender Affirming Care Covered | 40.00% Coinsurance after deductible | 60.00% Coinsurance after deductible | Prior Authorization requried |
Free Preventive Services
There is no copayment or coinsurance for any of the following Sanford Simplicity – Standardized $5,800 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 Simplicity – Standardized $5,800 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 Simplicity - Standardized $5,800?
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