Sanford Individual TRUE $4,750 – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $45 copay
Specialist visit: $65 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $4,750 per person $4,750 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $45 copay |
| Specialist visit | $65 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 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 | $45 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $30 copay |
| Brand | This is the amount you will pay for a generic drug prescription. |
| Non-preferred Brand | $150 copay |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $45 copay |
| Imaging (CT/PET/MRI) | 50% coinsurance after deductible |
| Blood work | $45 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $45 copay |
| Psychiatric hospital stay | 50% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.sanfordhealthplan.org/-/media/plan-documents/2024/_IND_TRUE_SD_4750_HP2937.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=SHPISTP |
