Sanford Simplicity $3,500 - 89364ND0120003 Health Insurance Plan

Elective abortion services are only covered in cases of rape, incest, or when mother?s life is endangered. Prior Authorization/certification required.

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

Benefit includes serum, injections, testing and treatment

Limit: 1.0 Procedure(s) per Lifetime

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

Limit: 20.0 Visit(s) per Benefit Period

Chiropractic services provided on an inpatient or outpatient basis when Medically Appropriate and Necessary and within the scope of licensure and practice of a Chiropractor, to the extent services would be covered if provided by a Physician.

A newborn is covered from birth through 60 days on the subscriber's plan until they are appropriately enrolled. Deductible Amount is waived when the newborn is released with the mother.

Limit: 1.0 Visit(s) per 6 Months

Limit: 8.0 Visit(s) per Benefit Period

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

Medically Appropriate and Necessary Ambulance Services to the nearest facility equipped to provide the required level of care, including transportation: from the home or site of an Emergency Medical Condition; between hospitals; and between a Hospital and Skilled Nursing Facility.

Limit: 1.0 Item(s) per Benefit Period

Prescription Medications or Drugs and nonprescription diabetic supplies are subject to a dispensing limit of a 90-day supply.

Limit: 30.0 Visit(s) per Benefit Period

Cover health care services and devices that help a person keep, learn, or improve skills and functioning for daily living (habilitative services) up through the age of 18.

Limit: 1.0 Item(s) per 3 Years

Must have hearing loss that is not corrected by other covered procedures.

Limit: 40.0 Visit(s) per Benefit Period

Covered Services include: 1. The professional services of an R.N., Licensed Vocational Nurse or L.P.N.; 2. Physical, Occupational or Speech Therapy; 3. Medical and surgical supplies; 4. Administration of prescribed drugs; 5. Oxygen and the administration of oxygen; and 6. Health aide services for a Member who is receiving covered Skilled Nursing Services or Therapy Services. A visit is considered up to 4 continuous hours.

Hospice benefits are provided only for the treatment of Members diagnosed with a condition where there is a life expectancy of 6 months or less.

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)

Covered Services include the provision of nutrients, antibiotics, and other drugs and fluids intravenously, through a feeding tube, or by inhalation; all Medically Appropriate and Necessary supplies; and therapeutic drugs or other substances. Covered Services also include Medically Appropriate and Necessary enteral feedings when such feedings are the sole source of nutrition for a Member.

For psychiatric services, prior authorization required for inpatient, residential treatment, and partial hospitalization.

For psychiatric services, prior authorization required for inpatient, residential treatment, and partial hospitalization.

Limit: 12.0 Visit(s) per Benefit Period

Limit: 1.0 Treatment(s) per Lifetime

Only for the treatment of improper alignment of biting or chewing surfaces of upper and lower teeth through the installation of orthodontic appliances.

Limit: 30.0 Visit(s) per Benefit Period

Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. Benefits are not available for Maintenance Care.

Preventive screening services for Members age 6 and older according to A or B Recommendations of the U.S. Preventive Services Task Force and issued by the Health Resources and Services Administration.

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

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 up to $200

Reconstructive surgery to restore bodily function or correct deformity resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes.

Limit: 30.0 Visit(s) per Year

Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness. Benefits are not available for Maitenance Care.

Limit: 30.0 Visit(s) per Year

Rehabilitative Services: therapies that are designed to restore function following a surgery or medical procedure, injury or illness.

Vision examination is only covered when related to an illness or injury.

Limit: 1.0 Exam(s) per Benefit Period

Covered when medically appropriate.

Limit: 30.0 Days per Benefit Period

Preauthorization is required.

Specialty Drugs are subject to a dispensing limit of a 30-day supply.

Benefits are available for the inpatient treatment of substance abuse, including medically managed inpatient detoxification, medically monitored inpatient detoxification, medically managed intensive inpatient treatment or medically monitored intensive inpatient treatment, when provided at an appropriately licensed and credentialed Substance Abuse Facility. Benefits available for residential treatment for members under age 21. Benefits available for partial hospitalization. Preauthorization is required. For SUD, PA required for inpatient, residential, partial hospitalization, and intensive outpatient.

Outpatient benefits include diagnostic, evaluation and treatment services provided by a Physician, Licensed Clinical Psychologist or Licensed Addiction Counselor, including for gambling addiction.

Services must be performed at a qualified transplant center.

Limit: 1.0 Item(s) per Benefit Period

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

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