North Dakota health plan · 2025

Sanford Individual Simplicity $4,750 · 89364ND0120005

Sanford Health offers this marketplace health insurance plan (Plan ID 89364ND0120005) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Silver Plan type: PPO CSR: 73% AV Level Silver Plan Issuer: Sanford Health
Telehealth Data pending HSA eligible No Dental Child Vision Child
Pay / Manage Plan View issuer site

Issuer actuarial value: 73.66%. Expect to pay roughly 26.34% of covered costs out of pocket, based on issuer reporting.

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$359 – $1410

Before subsidies

Estimate after subsidies

Deductible

$4,750

$9500 per group

See deductible details

Max out-of-pocket

$6,950

$13900 per group

Review MOOP rules

Office visits

Primary care $45.00
Specialist $70.00
HSA Not eligible

Drug tiers

Generic $30.00
Preferred brand $40.00

View formulary tiers

$492 / mo before subsidies

≈ $5909 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$1560 / mo before subsidies

≈ $18725 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$1890 / mo before subsidies

≈ $22677 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$1201 / mo before subsidies

≈ $14411 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

No Charge

Emergency Room Services

40.00% Coinsurance after deductible

Durable Medical Equipment

40.00% Coinsurance after deductible

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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in North Dakota). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • 73% AV Level Silver Plan plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

No Charge

Emergency Room Services

40.00% Coinsurance after deductible

Durable Medical Equipment

40.00% Coinsurance after deductible

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 89364ND0120005
Coverage year 2025
State North Dakota
Issuer Sanford Health
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 89364ND0120005-04
Available variants

Standard Off Exchange Plan · 89364ND0120005-00

Standard On Exchange Plan · 89364ND0120005-01

Open to Indians below 300% FPL · 89364ND0120005-02

Open to Indians above 300% FPL · 89364ND0120005-03

73% AV Silver Plan · 89364ND0120005-04

87% AV Silver Plan · 89364ND0120005-05

94% AV Silver Plan · 89364ND0120005-06
Last plan update Fri, 14 Mar 2025 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in North Dakota N/A
PCPs in North Dakota N/A
Telehealth support Data pending
Nationwide providers N/A

Provider network(s)

Providers North Dakota All US states
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A

Drug coverage overview

5,440 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
GENERIC 2,572
NON-PREFERRED-BRAND 1,490
PREFERRED 779
NON-PREFERRED-BRAND-SPECIALTY 520
GENERIC-SPECIALTY 79
Prior authorization Drugs
Required 565
Not Required 4,875
Step therapy Drugs
Required 99
Not Required 5,341
Quantity limits Drugs
Has Limit 1,452
No Limit 3,988

Customer highlights

What stands out for members

  • Issuer: Sanford Health · Plan ID 89364ND0120005 · 2025 filing.
  • Disease management programs available: Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 89364ND0120005-04 (73% AV Silver Plan) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

$45.00
Tier 1 in-network $45.00
Out-of-network 70.00% Coinsurance after deductible

Limit: 20.0 Visit(s) per Benefit Period

nan

Exclusions: nan

Diabetes Education

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Home Health Care Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

Limit: 40.0 Visit(s) per Benefit Period

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

Exclusions: nan

Laboratory Outpatient and Professional Services

$45.00
Tier 1 in-network $45.00
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$45.00
Tier 1 in-network $45.00
Out-of-network 70.00% Coinsurance after deductible

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

Exclusions: nan

Preventive Care/Screening/Immunization

No Charge
Tier 1 in-network No Charge
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$45.00
Tier 1 in-network $45.00
Out-of-network 70.00% Coinsurance after deductible

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

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

$45.00
Tier 1 in-network $45.00
Out-of-network 70.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Year

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

Exclusions: nan

Rehabilitative Speech Therapy

$45.00
Tier 1 in-network $45.00
Out-of-network 70.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Year

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

Exclusions: nan

Specialist Visit

$70.00
Tier 1 in-network $70.00
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Urgent Care Centers or Facilities

$60.00
Tier 1 in-network $60.00
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

X-rays and Diagnostic Imaging

$45.00
Tier 1 in-network $45.00
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

Prior authorization is required.

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

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

Exclusions: nan

Dialysis

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

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

Exclusions: nan

Durable Medical Equipment

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

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

Emergency Room Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

nan

Exclusions: nan

Emergency Transportation/Ambulance

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

nan

Exclusions: nan

Hospice Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Inpatient Hospital Services (e.g., Hospital Stay)

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

Prior authorization is required.

Exclusions: nan

Inpatient Physician and Surgical Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Mental/Behavioral Health Inpatient Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

Prior authorization is required.

Exclusions: nan

Mental/Behavioral Health Outpatient Services

$45.00
Tier 1 in-network $45.00
Out-of-network 70.00% Coinsurance after deductible

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

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Outpatient Rehabilitation Services

$45.00
Tier 1 in-network $45.00
Out-of-network 70.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Benefit Period

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

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Radiation

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

Prior authorization is required.

Exclusions: nan

Skilled Nursing Facility

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

Limit: 30.0 Days per Benefit Period

Preauthorization is required.

Exclusions: nan

Substance Abuse Disorder Inpatient Services

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

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

Exclusions: nan

Substance Abuse Disorder Outpatient Services

$45.00
Tier 1 in-network $45.00
Out-of-network 70.00% Coinsurance after deductible

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

Exclusions: nan

Transplant

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

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

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

No Charge
Tier 1 in-network No Charge
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Hearing Aids

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

Limit: 1.0 Item(s) per 3 Years

nan

Exclusions: nan

Major Dental Care - Child

40.00%
Tier 1 in-network 40.00%
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Prenatal and Postnatal Care

No Charge
Tier 1 in-network No Charge
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Routine Eye Exam for Children

No Charge
Tier 1 in-network No Charge
Out-of-network 70.00% Coinsurance after deductible

Limit: 1.0 Exam(s) per Benefit Period

nan

Exclusions: nan

Well Baby Visits and Care

No Charge
Tier 1 in-network No Charge
Out-of-network 70.00% Coinsurance after deductible

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

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

nan

Exclusions: nan

Non-Preferred Brand Drugs

$150.00
Tier 1 in-network $150.00
Out-of-network 100.00%

nan

Exclusions: nan

Preferred Brand Drugs

$40.00
Tier 1 in-network $40.00
Out-of-network 100.00%

nan

Exclusions: nan

Specialty Drugs

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

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

Exclusions: nan

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

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

Basic Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Dental Check-Up for Children

No Charge
Tier 1 in-network No Charge
Out-of-network 70.00% Coinsurance after deductible

Limit: 2.0 Exam(s) per Benefit Period

nan

Exclusions: nan

Infusion Therapy

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Nutritional Counseling

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

Limit: 12.0 Visit(s) per Benefit Period

nan

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

40.00%
Tier 1 in-network 40.00%
Out-of-network 70.00% Coinsurance after deductible

nan

Exclusions: nan

Prosthetic Devices

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

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

Routine Dental Services (Adult)

Coverage details pending

nan

Exclusions: nan

Weight Loss Programs

Coverage details pending

nan

Exclusions: nan

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

Coverage details pending

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

Exclusions: nan

Acupuncture

Coverage details pending

nan

Exclusions: nan

Allergy Testing

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

Benefit includes serum, injections, testing and treatment.

Exclusions: nan

Applied Behavior Analysis Based Therapies

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

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

Exclusions: nan

Bariatric Surgery

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

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

Exclusions: nan

Cosmetic Surgery

Coverage details pending

nan

Exclusions: nan

Eye Glasses for Children

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

Limit: 1.0 Item(s) per Benefit Period

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

Gender Affirming Care

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

Prior Authorization requried

Exclusions: nan

Habilitation Services

$45.00
Tier 1 in-network $45.00
Out-of-network 70.00% Coinsurance after deductible

Limit: 30.0 Visit(s) per Benefit Period

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

Exclusions: nan

Imaging (CT/PET Scans, MRIs)

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

Prior authorization may be required.

Exclusions: nan

Infertility Treatment

Coverage details pending

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

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Private-Duty Nursing

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

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

Reconstructive Surgery

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

Some services require prior authorization.

Exclusions: nan

Routine Eye Exam (Adult)

Coverage details pending

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)

Exclusions: nan

Routine Foot Care

Coverage details pending

Covered when medically appropriate.

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 70.00% Coinsurance after deductible

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

Variant attributes

Sanford Individual Simplicity $4,750 · Variant 89364ND0120005-04

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

73% AV Level Silver Plan

HIOS Product ID

89364ND012

Metal Level

Silver

Plan ID (Standard Component ID with Variant)

89364ND0120005-04

Plan Marketing Name

Sanford Individual Simplicity $4,750

Plan Variant Marketing Name

Sanford Individual Simplicity $4,750

Issuer & service area

Issuer-provided metadata for this variant.

Issuer Actuarial Value

73.66%

Issuer ID

89364

Issuer Marketplace Marketing Name

Sanford Health Plan

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

Yes

Network ID

NDN003

Out of Country Coverage

No

Out of Country Coverage Description

Only in Emergent Medical situations

Out of Service Area Coverage

Yes

Out of Service Area Coverage Description

Only in Emergent Medical situations

Service Area ID

NDS003

State Code

ND

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

Yes

Medical Drug Maximum Out of Pocket Integrated

Yes

SBC Scenario, Having a Baby, Coinsurance

$1,500

SBC Scenario, Having a Baby, Copayment

$10

SBC Scenario, Having a Baby, Deductible

$4,750

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$1,600

SBC Scenario, Having Diabetes, Deductible

$100

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$0

SBC Scenario, Treatment of a Simple Fracture, Copayment

$200

SBC Scenario, Treatment of a Simple Fracture, Deductible

$2,100

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group

$36400 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person

$18200 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual

$18,200

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance

40.00%

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group

$13900 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person

$6950 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual

$6,950

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group

$36400 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person

$18200 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual

$18,200

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

NDF008

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$60

SBC Scenario, Having Diabetes, Limit

$20

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

5

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Dental Only Plan

No

Design Type

Not Applicable

Disease Management Programs Offered

Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy

EHB Percent of Total Premium

1.0

First Tier Utilization

100%

Import Date

2025-03-14 02:01:36

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

No

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

PPO

QHP/Non QHP

Both

Source Name

HIOS

Plan ID

89364ND0120005

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group

$19000 per group

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person

$9500 per person

Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual

$9,500

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group

$9500 per group

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person

$4750 per person

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual

$4,750

Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group

$19000 per group

Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person

$9500 per person

Combined Medical and Drug EHB Deductible, Out of Network, Individual

$9,500

Unique Plan Design

Yes

Wellness Program Offered

No

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in North Dakota?

Sanford Individual Simplicity $4,750 (89364ND0120005) is a Silver PPO from Sanford Health in North Dakota for the 2025 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does Sanford Individual Simplicity $4,750 support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is Sanford Individual Simplicity $4,750 HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental add-ons: Child.

Vision add-ons: Child.

Does Sanford Individual Simplicity $4,750 support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with Sanford Individual Simplicity $4,750?

The issuer lists disease management resources for: Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy.

Is there out-of-country coverage for Sanford Individual Simplicity $4,750?

No, out-of-country services are not covered for this plan. Details: Only in Emergent Medical situations

Does Sanford Individual Simplicity $4,750 cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Only in Emergent Medical situations

How do I enroll in or manage payments for Sanford Individual Simplicity $4,750?

Use the issuer portal https://hix.sanfordhealthplan.com/ to pay premiums or start enrollment, then return to HealthPorta for benefit comparisons.

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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