Sanford TRUE $7,000 - 31195SD0080019 Health Insurance Plan

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

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

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

Limit: 2.0 Visit(s) per Year

Certain dental services may require authorization (pre-approval) by the plan.

Limit: 8.0 Visit(s) per Benefit Period

Quantity Limit: Two certified diabetes education programs per member per lifetime, and eight visits per benefit year for follow-up training once patient has participated in a diabetes education program.

Equipment must primarily and customarily serve a medical purpose. Issuer determines whether to pay the rental amount or the purchase price amount for an item and determine the length of any rental term. Prior authorization may be required.

Limit: 1.0 Item(s) per Year

Limited to 1 frame every other year.

Prior Authorization requried

Generic drugs less than $6 are covered at no charge. Covers up to a 30-day supply. Generic cost is based on total drug cost per 30-day supply. Brand name drugs with generic equivalents require additional cost share. Difference in cost does not apply to deductible or out-of-pocket limit. There are no limitations or restrictions for use of manufacturer coupons if used in conjunction with our current benefit offering.

Treatment for Autism Spectrum Disorder (ASD) with speech therapy, occupational therapy, or physical therapy is covered. Use of Applied Behavioral Analysis (ABA) for the treatment of ASD is covered with the following minimum coverage limits: 1) through age 6: 1300 hours per benefit period; 2) ages 7-13: 900 hours per benefit period; 3) ages 14-18: 450 hours per benefit period. Other outpatient services are subject to deductible/coinsurance.

Limit: 1.0 Item(s) per 3 Years

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

Prior authorization required.

Hospice respite care limited to 15 inpatient and 15 outpatient days per lifetime. Hospice respite care must be used in increments of not more than 5 days at a time.

Prior authorization may be required

Infusion therapy is covered when provided in the home (home infusion therapy).

Prior authorization may be required

Other outpatient services are subject to deductible/coinsurance.

Limit: 12.0 Visit(s) per Benefit Period

Prior authorization may be required

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. Other outpatient services are subject to deductible/coinsurance.

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

Occupational therapy is only covered insofar as services to treat the upper extremities, which means the arms from the shoulders to the fingers. Other outpatient services are subject to deductible/coinsurance.

Coverage includes rehabilitative speech therapy services when related to a specific illness, injury, or impairment and involve the mechanics of phonation, articulation, or swallowing. Services must be provided by a licensed or certified speech pathologist. Other outpatient services are subject to deductible/coinsurance.

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

Limit: 1.0 Exam(s) per Year

Covered when medically appropriate.

Limit: 90.0 Days per Year

Preauthorization is required.

Other outpatient services are subject to deductible/coinsurance.

Limit: 1.0 Exam(s) per Transplant

Transplants are subject to Case Management.

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.