Sanford Individual Simplicity Enhanced Care Plan $3,700 HSA Qualified – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$3,700 per person $3,700 per person
Out-of-pocket max	$7,050 per person $14,100 per family
Metal tier	Silver

Visit Copay

Primary care visit	15% coinsurance after deductible
Specialist visit	15% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

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

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	15% coinsurance after deductible

Pharmacy, Drugs, and Medication

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

Lab Tests and Diagnostic Procedures

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

Mental and Psychiatric Health Care

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

Health Plan Provider Information

Health Plan Benefits	https://www.sanfordhealthplan.org/-/media/plan-documents/2024/_IND_SIMPLICITY_SD_3700_ENHANCED_HSAQUALIFIED_HP5260.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