Sanford Individual Simplicity Standardized $1,500 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$1,500 per person $1,500 per person
Out-of-pocket max	$8,700 per person $17,400 per family
Metal tier	Gold

Visit Copay

Primary care visit	$30 copay
Specialist visit	$60 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$45 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	$30 copay

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	$60 copay
Specialty	$250 copay

Lab Tests and Diagnostic Procedures

X-rays	25% coinsurance after deductible
Imaging (CT/PET/MRI)	25% coinsurance after deductible
Blood work	25% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$30 copay
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_1500_STANDARD_HP5264.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