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

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

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.

Limited to 2 routine check-up visits per calendar year. Preventive, emergency, and routine coverage available for members up to age 19. See your plan document for eligible services. Certain outpatient services may require authorization (pre-approval) by the plan. For a list of services, see the Prior Authorization list at sanfordhealthplan.com.

Prior authorization is required.

Limit: 2.0 Exam(s) per Benefit Period

Limited to 2 routine check-up visits per calendar year. Preventive, emergency, and routine coverage available for members up to age 19. See your plan document for eligible services. Certain outpatient services may require authorization (pre-approval) by the plan. For a list of services, see the Prior Authorization list at sanfordhealthplan.com.

Limit: 8.0 Visit(s) per Benefit Period

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

Prior authorization is required for certain items.

Limit: 1.0 Exam(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.

Prior Authorization requried

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 or biosimilar alternatives 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. If the cost of the prescription falls under the copay amount, you will pay the least. Refer to your Formulary to determine which benefit applies to your medication.

Limit: 1.0 Item(s) per 3 Years

When medically necessary for conditions including, but not limited to: sudden sensorineural hearing loss (SSNHL), accident, injury or related illness.

Prior authorization is 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.

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)

Prior authorization is required.

Prior authorization is required.

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 or biosimilar alternatives 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. If the cost of the prescription falls under the copay amount, you will pay the least. Refer to your Formulary to determine which benefit applies to your medication.

Limit: 12.0 Visit(s) per Benefit Period

Certain outpatient services may require authorization (pre-approval) by the Plan. For a list of services, see the Prior Authorization list at sanfordhealthplan.com.

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 or biosimilar alternatives 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. If the cost of the prescription falls under the copay amount, you will pay the least. Refer to your Formulary to determine which benefit applies to your medication.

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.

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.

Prior authorization is required.

Some services require prior authorization.

Office visit copay covers evaluation.

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

Limited to 1 visit per calendar year. Benefit ends at the end of the month when the member turns 19.

Covered when medically appropriate.

Limit: 90.0 Days per Benefit Period

Prior authorization is required. Limited to 90 days in any consecutive 12 month period.

Preferred and Non-Preferred specialty drugs may be subject to different cost sharing rates. 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 or biosimilar alternatives 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. If the cost of the prescription falls under the copay amount, you will pay the least. Refer to your Formulary to determine which benefit applies to your medication.

Prior authorization is required.

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.

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.