Exclusions: nan

Elective abortion services are only covered when the mothers life is endangered. Prior Authorization/certification required.

Exclusions: nan

Oral surgical procedures limited to services required because of injury, accident or cancer that damages Natural Teeth. This is an Outpatient Surgery that requires Certification. Care must be received within twelve 12 months of the occurrence. Injury does not include injuries to Natural Teeth caused by biting or chewing. Associated radiology services are included. Coverage applies regardless of whether the services are provided in a Hospital or a dental office. Extractions when medically necessary because of injury, accident, or cancer when internal guidelines are met.

Exclusions: nan

nan

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Benefit includes serum, injections, testing and treatment.

Exclusions: nan

Covered service for the treatment of Autism Spectrum Disorder. Prior Authorization required.

Exclusions: nan

Surgery must be medically necessary. Not all procedures classified as weight reduction surgery are covered. Prior approval for weight reduction surgery is required.

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Prior authorization is required.

Limit: 20.0 Visit(s) per Benefit Period

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Deductible Amount is waived when the newborn is released with the mother

Limit: 2.0 Exam(s) per Benefit Period

Exclusions: nan

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Plan will pay first for the first 30 months after you become eligible to join Medicare.

Exclusions: nan

Coverage for DME prescribed by an attending Practitioner and/or Provider, which is Medically Necessary, not primarily and customarily used for non-medical purposes, designed for prolonged use, and for a specific therapeutic purpose in the treatment of an illness or injury. Limitations per Sanford Health Plan policy guidelines apply. Casts, splints, braces, crutches and dressings for the treatment of fracture, dislocation, torn muscles or ligaments and other chronic conditions per Sanford Health Plan policy. Prior authorization is required for certain items.

Exclusions: nan

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Limit: 1.0 Item(s) per Benefit Period

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Limited to 1 frame every other year. Lenses or contact lenses limited to 1 item annually. Benefit ends at the end of the month when the member turns 19.

Exclusions: nan

Prior Authorization requried

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Limit: 30.0 Visit(s) per Benefit Period

Exclusions: nan

First 5 office visits covered at 100% in the combined categories of Primary Care, Habilitation, and Rehabilitation.

Limit: 1.0 Item(s) per 3 Years

Exclusions: nan

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Limit: 40.0 Visit(s) per Benefit Period

Exclusions: nan

Prior authorization is required in lieu of a Hospital or Skilled Nursing Facility stay.

Exclusions: nan

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Prior authorization may be required.

Exclusions: nan

Testing for the diagnosis of infertility: Transvaginal ultrasound for structural evaluation (limit of 1 per calendar year) Sonogram (limit of 1 per calendar year) Screenings for stimulations of ovarian reserves and ovarian functions(limit of 1 per screening per calendar year) Screenings for assessment of polycystic ovarian syndrome (PCOS) (limit of 1 per calendar year) Semen Analysis (limit of 2 per calendar year)

Exclusions: nan

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Prior authorization is required.

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Prior authorization is required.

Exclusions: nan

First 5 office visits covered at 100% in the combined categories of Mental/Behavioral Health and SUD. The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for additional information.

Exclusions: nan

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Limit: 12.0 Visit(s) per Benefit Period

Exclusions: nan

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First 5 office visits covered at 100% in the combined categories of Primary Care, Habilitation, and Rehabilitation.

Exclusions: nan

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Limit: 30.0 Visit(s) per Benefit Period

Exclusions: nan

First 5 office visits covered at 100% in the combined categories of Primary Care, Habilitation, and Rehabilitation.

Exclusions: nan

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First 5 office visits covered at 100% in the combined categories of Primary Care, Habilitation, and Rehabilitation.

Exclusions: nan

Nursing care that is provided to a Member on a one-to-one basis by licensed nurse in an inpatient or home setting. Prior authorization is required.

Exclusions: nan

Prosthetic limbs, sockets and supplies, and prosthetic eyes; Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy. Includes two (2) external prosthesis per Calendar Year and six (6) bras per Calendar Year. For double mastectomy: coverage extends to four (4) external prosthesis per Calendar Year and six (6) bras per Calendar Year. Devices permanently implanted that are not Experimental or Investigational Services such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy. Cranial Prosthesis, including wigs (limited to 1 per benefit period)Prosthetic limbs, sockets and supplies, and prosthetic eyes. Requires Prior Authorization.

Exclusions: nan

Prior authorization is required.

Exclusions: nan

Some services require prior authorization.

Limit: 30.0 Visit(s) per Year

Exclusions: nan

First 5 office visits covered at 100% in the combined categories of Primary Care, Habilitation, and Rehabilitation.

Limit: 30.0 Visit(s) per Year

Exclusions: nan

First 5 office visits covered at 100% in the combined categories of Primary Care, Habilitation, and Rehabilitation.

Exclusions: nan

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Exclusions: nan

Vision examination is only covered when related to injury, accident or cancer that damages the eye. Dilated eye examination for diabetes-related diagnosis (limit of one exam per Member per year)

Limit: 1.0 Exam(s) per Benefit Period

Exclusions: nan

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Covered when medically appropriate.

Limit: 30.0 Days per Benefit Period

Exclusions: nan

Preauthorization is required.

Exclusions: nan

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Preferred and Non-Preferred specialty drugs may be subject to different cost sharing rates.

Exclusions: nan

For SUD, PA required for inpatient, residential, partial hospitalization, and intensive outpatient.

Exclusions: nan

First 5 office visits covered at 100% in the combined categories of Mental/Behavioral Health and SUD.

Exclusions: nan

Prior authorization is required. To be eligible for coverage, Transplants must meet United Network for Organ Sharing (UNOS) criteria and/or Medical Criteria. Transplants must be performed at contracted Centers of Excellence or otherwise identified and accepted by Sanford Health Plan as qualified facilities.

Exclusions: nan

Services for the Treatment and Diagnosis of TMJ/TMD are covered subject to Medical Necessity. Manual therapy and osteopathic or chiropractic manipulation treatment if performed by physical medicine Providers. TMJ Splints and adjustments if your primary diagnosis is TMJ/TMD. Maximum Benefit Allowance of 1 splint per Member per Benefit Period.

Exclusions: nan

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Exclusions: nan

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Well Child Care to the Member's 6th birthday, 100% of Allowed Charges.

Exclusions: nan

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