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Sanford Health Plan

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Health Insurance FAQ's


We know insurance can be confusing. We are here to keep it simple. Below find information on our top  general health insurance questions we receive from our members!


I haven’t received my ID card yet and am requiring services, what should I do?
Doctor visit:  Verify the physician or facility is participating with Sanford Health Plan, inform the clinic at check-in that you are currently enrolling with Sanford Health Plan.

Prescription:  You will be required to pay for the prescription in full. Once you receive your ID card, the pharmacy may be able to re-process your claim if you provide your ID card within 10 days from the date that the prescription(s) was filled. If this is not possible, you will  need to submit a claim form and send the  prescription receipt to Sanford Health Plan for reimbursement. Claim forms are available from Sanford Health Plan.
What does all the information on the front of my ID card mean?
SHP ID Card

Always remember, the identification card is to be used only by the person listed on the card. It may not be used by anyone else. Use of your card by another person is fraud and will be grounds for termination from the Plan. Should you need to replace a lost card, please call the Member Services Department at (605) 328-6800 or (800) 752-5863 and we will send you a new one.
What does all the information on the back of my ID card mean?
SHP ID Card
Always remember, the identification card is to be used only by the person listed on the card. It may not be used by anyone else. Use of your card by another person is fraud and will be grounds for termination from the Plan. Should you need to replace a lost card, please call the Member Services Department at (605) 328-6800 or (800) 752-5863 and we will send you a new one.
What is a “formulary” and where can I find the drugs included?
A formulary is a list which identifies those prescription drug products which are preferred by the medical insurance plan for dispensing to you when appropriate. The list is reviewed and modified each year. You can find a list of the formulary drug names in your enrollment booklet along with a description of pharmacy management procedures.
What pharmacies can I use to fill my prescriptions?

Pharmacies that have contracted with Express Scripts, Inc., on behalf of Sanford Health Plan are considered to be participating pharmacies. You can find a listing of participating pharmacies. If you choose to go to a non-participating pharmacy, you will have to pay full-price for the prescription, rather than your copay.

Am I able to get more than a 30 day supply on some of my medications?
For some medications including maintenance drugs or those that treat a chronic condition up to a 90 day supply is allowed. You will pay a copay for each 30 day supply received.
Who can I call if I feel that I was not charged the correct amount for my prescriptions at the pharmacy?

Contact the Pharmacy Management Department and a representative will review your charges with you.

What doctors can I see with Sanford Health Plan?

To ensure you are receiving in-network benefit coverage, you are required to use the specific network tied to your plan. You can find participating providers here

What if there aren’t participating Sanford Health Plan providers in my residential area?
Sanford Health Plan has contracted with other networks for those members who reside, travel or attend school outside the Sanford Health Plan service area.  If you have an additional network listed on your identification card, you may seek medical care from a provider that is participating with the additional network.  If these additional networks do not provide you with access to a needed provider, the Sanford Health Plan Access and Availability rules will apply.  Please refer to your Policy for details.  You can find the links to the additional networks available to you here or by calling Member Services at 1-800-752-5863.  If you have questions or do not have access to our website and would like to request a printed provider Directory, please call Member Services. IMPORTANT:  If you choose to go to a non-participating provider when in network access is available, your claims will be paid according to your out-of-network benefits.
What if I need to see a specialist?
Sanford Health Plan does not require a referral from your primary care physician to see a specialist who is in the network. If the specialist is NOT a participating provider, you must contact Sanford Health Plan to request authorization. If authorization is received, your benefits will be considered In-Network. Failure to obtain prior authorization may result in reduced coverage to the specialty services.

What if I must call after hours or on a weekend for an authorization, urgent/emergency service or to report use at an out-of-area provider?
Sanford Health Plan has an after-hours voice mail service. If you use this voice mail service, it is very important to leave a message including your name, your ID number (as shown on your ID card), and a phone number where you can be reached. Your call will be returned the following business day.
Do I need to prior authorize for a colonoscopy or endoscopy/EGD?
No, as long as the provider is considered an in-network Sanford Health Plan provider.
I am pregnant; do I need to tell my insurance?
We prefer you call us so you can enroll in the Healthy Pregnancy Program. You will receive free information on pregnancy and prenatal care.
Does my benefit package cover weight loss surgery?
This depends on your benefit package. Most packages have some coverage for bariatric surgery; however specific criteria must be met. Prior authorization is also required along with a letter from your doctor.

What if another insurance company is involved in paying for my injury/illness?

Sanford Health Plan partners with a company called Optum. This company helps to research claims that may be work-related or accident-related, such as an automobile accident. Optum helps us determine who is responsible for your charges.  This process is called subrogation.

If you receive a call or letter from Optum requesting information on behalf of Sanford Health Plan, please know that all information will be held in strict confidence and used only to determine who should pay for your services. Please answer their questions promptly so your claims are not delayed or denied.

For more information or to submit information visit https://icc.optum.com/

Who is Optum and why are they calling me?

Who is Optum?

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Tell Us About Yourself

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Purchasing through Sanford Health Plan or the Marketplace, let us explain the differences

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Tell Us About Yourself

Insurance terms are confusing. Let us help make sense of it all.

Purchasing through Sanford Health Plan or the Marketplace, let us explain the differences

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Tell Us About Yourself

Insurance terms are confusing. Let us help make sense of it all.

Purchasing through Sanford Health Plan or the Marketplace, let us explain the differences

Sanford Health Plan offers two different provider network products in your area. Select what option that best fits your needs.

Click here to search our provider directory. If your doctor does not display, they most likely are not a participating provider with Sanford Health Plan. Feel free to continue the Plan Picker tool if you are still interested in what options Sanford Health Plan has to offer. If not, we appreciate you using our Plan Picker!

Please complete all steps in the questionnaire to see your results.