Sanford TRUE Enhanced – Diabetes & Asthma/COPD Care Plan $1,250
89364ND0090025
Gold
HMO
Sanford TRUE Enhanced – Diabetes & Asthma/COPD Care Plan $1,250 is a Gold HMO plan by Sanford Health Plan.
IMPORTANT: You are viewing the 2023 version of Sanford TRUE Enhanced – Diabetes & Asthma/COPD Care Plan $1,250 89364ND0090025. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
Sanford TRUE Enhanced – Diabetes & Asthma/COPD Care Plan $1,250 is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of Sanford TRUE Enhanced – Diabetes & Asthma/COPD Care Plan $1,250 89364ND0090025.
| Insurer: | Sanford Health Plan |
| Network Type: | HMO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 89364ND0090025 |
Cost-Sharing Overview
Sanford TRUE Enhanced – Diabetes & Asthma/COPD Care Plan $1,250 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Sanford TRUE Enhanced – Diabetes & Asthma/COPD Care Plan $1,250 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $5,500.00 | $5500 per person | $11000 per group |
| Deductible: | $1,250.00 | $1250 per person | $2500 per group |
| Coinsurance: | 25.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Sanford TRUE Enhanced – Diabetes & Asthma/COPD Care Plan $1,250 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | $1,250.00 (in-and-out of network) | $1250 per person (in-and-out of network) | $2500 per group (in-and-out of network) |
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: | $1,250.00 |
| Copayment: | $0.00 |
| Coinsurance: | $1,800.00 |
| Limit: | $60.00 |
| Deductible: | $100.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $1,300.00 |
| Copayment: | $0.00 |
| Coinsurance: | $200.00 |
| 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 TRUE Enhanced - Diabetes & Asthma/COPD Care Plan $1,250?
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 TRUE Enhanced – Diabetes & Asthma/COPD Care Plan $1,250 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 TRUE Enhanced – Diabetes & Asthma/COPD Care Plan $1,250 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 TRUE Enhanced – Diabetes & Asthma/COPD Care Plan $1,250 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 | 25.00% Coinsurance after deductible | 100.00% | |
| Specialist Visit Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Hospice Services Covered | 25.00% Coinsurance after deductible | 100.00% | Hospice benefits are provided only for the treatment of Members diagnosed with a condition where there is a life expectancy of 6 months or less. |
| 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 | 25.00% Coinsurance after deductible | 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 |
| Routine Eye Exam (Adult) Not Covered | Vision examination is only covered when related to an illness or injury. | ||
| Urgent Care Centers or Facilities Covered | 25.00% Coinsurance after deductible | 25.00% Coinsurance after deductible | |
| Home Health Care Services Covered | 25.00% Coinsurance after deductible | 100.00% | 40 Visit(s) per Benefit Period Covered Services include: 1. The professional services of an R.N., Licensed Vocational Nurse or L.P.N.; 2. Physical, Occupational or Speech Therapy; 3. Medical and surgical supplies; 4. Administration of prescribed drugs; 5. Oxygen and the administration of oxygen; and 6. Health aide services for a Member who is receiving covered Skilled Nursing Services or Therapy Services. A visit is considered up to 4 continuous hours. |
| Emergency Room Services Covered | 25.00% Coinsurance after deductible | 25.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | 25.00% Coinsurance after deductible | 25.00% Coinsurance after deductible | Medically Appropriate and Necessary Ambulance Services to the nearest facility equipped to provide the required level of care, including transportation: from the home or site of an Emergency Medical Condition; between hospitals; and between a Hospital and Skilled Nursing Facility. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Inpatient Physician and Surgical Services Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Bariatric Surgery Covered | 25.00% Coinsurance after deductible | 100.00% | 1 Procedure(s) per Lifetime 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 | 25.00% Coinsurance after deductible | 100.00% | 30 Days per Benefit Period Preauthorization is required. |
| Prenatal and Postnatal Care Covered | No Charge | 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | 25.00% Coinsurance after deductible | 100.00% | A newborn is covered from birth through 60 days on the subscriber’s plan until they are appropriately enrolled. |
| Mental/Behavioral Health Outpatient Services Covered | 25.00% Coinsurance after deductible | 100.00% | For psychiatric services, prior authorization required for inpatient, residential treatment, and partial hospitalization. |
| Mental/Behavioral Health Inpatient Services Covered | 25.00% Coinsurance after deductible | 100.00% | For psychiatric services, prior authorization required for inpatient, residential treatment, and partial hospitalization. |
| Substance Abuse Disorder Outpatient Services Covered | 25.00% Coinsurance after deductible | 100.00% | Outpatient benefits include diagnostic, evaluation and treatment services provided by a Physician, Licensed Clinical Psychologist or Licensed Addiction Counselor, including for gambling addiction. |
| Substance Abuse Disorder Inpatient Services Covered | 25.00% Coinsurance after deductible | 100.00% | Benefits are available for the inpatient treatment of substance abuse, including medically managed inpatient detoxification, medically monitored inpatient detoxification, medically managed intensive inpatient treatment or medically monitored intensive inpatient treatment, when provided at an appropriately licensed and credentialed Substance Abuse Facility. Benefits available for residential treatment for members under age 21. Benefits available for partial hospitalization. Preauthorization is required. For SUD, PA required for inpatient, residential, partial hospitalization, and intensive outpatient. |
| Generic Drugs Covered | 25.00% Coinsurance after deductible | 100.00% | Prescription Medications or Drugs and nonprescription diabetic supplies are subject to a dispensing limit of a 90-day supply. |
| Preferred Brand Drugs Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Non-Preferred Brand Drugs Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Specialty Drugs Covered | 25.00% Coinsurance after deductible | 100.00% | Specialty Drugs are subject to a dispensing limit of a 30-day supply. |
| Outpatient Rehabilitation Services Covered | 25.00% Coinsurance after deductible | 100.00% | 30 Visit(s) per Benefit Period 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. |
| Habilitation Services Covered | 25.00% Coinsurance after deductible | 100.00% | 30 Visit(s) per Benefit Period Cover health care services and devices that help a person keep, learn, or improve skills and functioning for daily living (habilitative services) up through the age of 18. |
| Chiropractic Care Covered | 25.00% Coinsurance after deductible | 100.00% | 20 Visit(s) per Benefit Period Chiropractic services provided on an inpatient or outpatient basis when Medically Appropriate and Necessary and within the scope of licensure and practice of a Chiropractor, to the extent services would be covered if provided by a Physician. |
| Durable Medical Equipment Covered | 25.00% Coinsurance after deductible | 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 |
| Hearing Aids Covered | 25.00% Coinsurance after deductible | 100.00% | 1 Item(s) per 3 Years Must have hearing loss that is not corrected by other covered procedures. |
| Imaging (CT/PET Scans, MRIs) Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Preventive Care/Screening/Immunization Covered | No Charge | 100.00% | Preventive screening services for Members age 6 and older according to A or B Recommendations of the U.S. Preventive Services Task Force and issued by the Health Resources and Services Administration. |
| 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 | 100.00% | 1 Exam(s) per Benefit Period |
| Eye Glasses for Children Covered | 25.00% Coinsurance after deductible | 100.00% | 1 Item(s) per Benefit Period |
| Dental Check-Up for Children Covered | No Charge | 100.00% | 1 Visit(s) per 6 Months |
| Rehabilitative Speech Therapy Covered | 25.00% Coinsurance after deductible | 100.00% | 30 Visit(s) per Year Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | 25.00% Coinsurance after deductible | 100.00% | 30 Visit(s) per Year Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. Benefits are not available for Maitenance Care. |
| Well Baby Visits and Care Covered | No Charge | 100.00% | Well Child Care to the Member’s 6th birthday, 100% of Allowed Charge. |
| Laboratory Outpatient and Professional Services Covered | 25.00% Coinsurance after deductible | 100.00% | |
| X-rays and Diagnostic Imaging Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Basic Dental Care – Child Covered | No Charge | 100.00% | |
| Orthodontia – Child Covered | 25.00% Coinsurance after deductible | 100.00% | 1 Treatment(s) per Lifetime Only for the treatment of improper alignment of biting or chewing surfaces of upper and lower teeth through the installation of orthodontic appliances. |
| Major Dental Care – Child Covered | 25.00% Coinsurance after deductible | 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 in cases of rape, incest, or when mother?s life is endangered. Prior Authorization/certification required. | ||
| Transplant Covered | 25.00% Coinsurance after deductible | 100.00% | Services must be performed at a qualified transplant center. |
| Accidental Dental Covered | 25.00% Coinsurance after deductible | 100.00% | 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 | 25.00% Coinsurance after deductible | 100.00% | |
| Allergy Testing Covered | 25.00% Coinsurance after deductible | 100.00% | Benefit includes serum, injections, testing and treatment |
| Chemotherapy Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Radiation Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Diabetes Education Covered | 25.00% Coinsurance after deductible | 100.00% | 8 Visit(s) per Benefit Period |
| Prosthetic Devices Covered | 25.00% Coinsurance after deductible | 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 up to $200 |
| Infusion Therapy Covered | 25.00% Coinsurance after deductible | 100.00% | Covered Services include the provision of nutrients, antibiotics, and other drugs and fluids intravenously, through a feeding tube, or by inhalation; all Medically Appropriate and Necessary supplies; and therapeutic drugs or other substances. Covered Services also include Medically Appropriate and Necessary enteral feedings when such feedings are the sole source of nutrition for a Member. |
| Treatment for Temporomandibular Joint Disorders Covered | 25.00% Coinsurance after deductible | 100.00% | 1 Item(s) per Benefit Period 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 | 25.00% Coinsurance after deductible | 100.00% | 12 Visit(s) per Benefit Period |
| Reconstructive Surgery Covered | 25.00% Coinsurance after deductible | 100.00% | Reconstructive surgery to restore bodily function or correct deformity resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes. |
| Gender Affirming Care Covered | 25.00% Coinsurance after deductible | 100.00% | |
| Applied Behavior Analysis Based Therapies Covered | 25.00% Coinsurance after deductible | 100.00% |
Free Preventive Services
There is no copayment or coinsurance for any of the following Sanford TRUE Enhanced – Diabetes & Asthma/COPD Care Plan $1,250 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 TRUE Enhanced – Diabetes & Asthma/COPD Care Plan $1,250 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 TRUE Enhanced - Diabetes & Asthma/COPD Care Plan $1,250?
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