Sanford Individual Simplicity Standardized $7,500 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$7,500 per person $7,500 per person
Out-of-pocket max	$9,400 per person $18,800 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$50 copay
Specialist visit	$100 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$75 copay
Emergency room	50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	$50 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$25 copay
Brand	This is the amount you will pay for a generic drug prescription.
Non-preferred Brand	$100 copay after deductible
Specialty	$500 copay after deductible

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	50% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$50 copay
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.sanfordhealthplan.org/-/media/plan-documents/2024/_IND_SIMPLICITY_SD_7500_EXPANDED_STANDARD_HP5262.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