Sanford Individual Simplicity $1,750 – PPO

Network type: PPO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $25 copay
Urgent care visit: $30 copay

SKU: 31195SD0110001 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type PPO
Deductible $1,750 per person $1,750 per person
Out-of-pocket max $8,450 per person $16,900 per family
Metal tier Gold

Visit Copay

Primary care visit $15 copay
Specialist visit $25 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $30 copay
Emergency room 30% coinsurance after deductible
Ambulance 30% coinsurance after deductible
Hospital stay (facility) 30% coinsurance after deductible
Hospital stay (physician) 30% coinsurance after deductible
Outpatient procedure (facility) 30% coinsurance after deductible
Outpatient procedure (physician) 30% coinsurance after deductible
Physical rehabilitation $15 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $15 copay
Brand This is the amount you will pay for a generic drug prescription.
Non-preferred Brand $125 copay
Specialty 30% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays $15 copay
Imaging (CT/PET/MRI) 30% coinsurance after deductible
Blood work $15 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $15 copay
Psychiatric hospital stay 30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.sanfordhealthplan.org/-/media/plan-documents/2024/_IND_SIMPLICITY_SD_1750_HP2901.pdf
Drug and medication plan formulary https://www.sanfordhealthplan.com/-/media/files/documents/members/hp6911-simplicity-and-true-for-individual-and-small-groups-1124.pdf
Search doctor list https://www3.viiad.com/shp/public/default.asp?SelectedPlan=SHPISP