Sanford Individual Simplicity $2,800 – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $20 copay
Urgent care visit: $15 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $2,800 per person $2,800 per person |
| Out-of-pocket max | $8,450 per person $16,900 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $20 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $15 copay |
| Emergency room | 25% coinsurance after deductible |
| Ambulance | 25% coinsurance after deductible |
| Hospital stay (facility) | 25% coinsurance after deductible |
| Hospital stay (physician) | 25% coinsurance after deductible |
| Outpatient procedure (facility) | 25% coinsurance after deductible |
| Outpatient procedure (physician) | 25% coinsurance after deductible |
| Physical rehabilitation | No charge |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 25% 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 | 25% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge |
| Imaging (CT/PET/MRI) | 25% coinsurance after deductible |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | 25% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.sanfordhealthplan.org/-/media/plan-documents/2024/_IND_SIMPLICITY_SD_2800_HP7029.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 |
