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Sanford TRUE – Standardized $7,500

31195SD0080026
Expanded Bronze
HMO

Sanford TRUE – Standardized $7,500 is an Expanded Bronze HMO plan by Sanford Health Plan.

IMPORTANT: You are viewing the 2023 version of Sanford TRUE – Standardized $7,500 31195SD0080026. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Sanford TRUE – Standardized $7,500 is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Sanford TRUE – Standardized $7,500 31195SD0080026.
Insurer: Sanford Health Plan
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 31195SD0080026

Cost-Sharing Overview

Sanford TRUE – Standardized $7,500 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 TRUE - Standardized $7,500?

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 TRUE – Standardized $7,500 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 TRUE – Standardized $7,500 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 TRUE – Standardized $7,500 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
$50.00 100.00%
Specialist Visit
Covered
$100.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$50.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
50.00% Coinsurance after deductible 100.00% Prior authorization may be required
Outpatient Surgery Physician/Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
50.00% Coinsurance after deductible 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
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
50.00% 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
$75.00 $75.00
Home Health Care Services
Covered
50.00% Coinsurance after deductible 100.00% Prior authorization required.
Emergency Room Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
50.00% Coinsurance after deductible 100.00% Prior authorization may be required
Inpatient Physician and Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
50.00% Coinsurance after deductible 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
50.00% Coinsurance after deductible 100.00%90 Days per Year Preauthorization is required.
Prenatal and Postnatal Care
Covered
No Charge 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
50.00% Coinsurance after deductible 100.00% Deductible Amount is waived when the newborn is released with the mother
Mental/Behavioral Health Outpatient Services
Covered
$50.00 100.00% Other outpatient services are subject to deductible/coinsurance.
Mental/Behavioral Health Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$50.00 100.00% Other outpatient services are subject to deductible/coinsurance.
Substance Abuse Disorder Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$25.00 100.00% 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
$50.00 Copay after deductible 100.00%
Non-Preferred Brand Drugs
Covered
$100.00 Copay after deductible 100.00%
Specialty Drugs
Covered
$500.00 Copay after deductible 100.00%
Outpatient Rehabilitation Services
Covered
$50.00 100.00% 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
$50.00 100.00% 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
$50.00 100.00%
Durable Medical Equipment
Covered
50.00% Coinsurance after deductible 100.00% 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
50.00% 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
50.00% Coinsurance after deductible 100.00% Prior authorization may be required
Preventive Care/Screening/Immunization
Covered
0.00% 100.00%
Routine Foot Care
Covered
50.00% Coinsurance after deductible 100.00% 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 Year
Eye Glasses for Children
Covered
50.00% Coinsurance after deductible 100.00%1 Item(s) per Year Limited to 1 frame every other year.
Dental Check-Up for Children
Covered
No Charge 100.00%2 Visit(s) per Year Certain dental services may require authorization (pre-approval) by the plan.
Rehabilitative Speech Therapy
Covered
$50.00 100.00% 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
$50.00 100.00% 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 100.00% Well Child Care to the Member’s 6th birthday, 100% of Allowed Charge.
Laboratory Outpatient and Professional Services
Covered
50.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
50.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Covered
No Charge 100.00%
Orthodontia – Child
Covered
50.00% Coinsurance after deductible 100.00%
Major Dental Care – Child
Covered
50.00% 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
Transplant
Covered
50.00% Coinsurance after deductible 100.00%1 Exam(s) per Transplant Transplants are subject to Case Management.
Accidental Dental
Covered
50.00% 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
50.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
50.00% Coinsurance after deductible 100.00% Benefit includes serum, injections, testing and treatment
Chemotherapy
Covered
50.00% Coinsurance after deductible 100.00%
Radiation
Covered
50.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
50.00% Coinsurance after deductible 100.00%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
50.00% 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
50.00% Coinsurance after deductible 100.00% Infusion therapy is covered when provided in the home (home infusion therapy).
Treatment for Temporomandibular Joint Disorders
Covered
50.00% Coinsurance after deductible 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
50.00% Coinsurance after deductible 100.00%12 Visit(s) per Benefit Period
Reconstructive Surgery
Covered
50.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
50.00% Coinsurance after deductible 100.00% Prior Authorization requried

Free Preventive Services

There is no copayment or coinsurance for any of the following Sanford TRUE – Standardized $7,500 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 TRUE – Standardized $7,500 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 TRUE - Standardized $7,500?

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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