Help & Important Documents

Browse our various resources and frequently asked questions below.

Resources & Forms

Evidence of Coverage (EOC)

2025

2024

Summary of Benefits Documents

2025

2024

Annual Notice of Change

2024

Medical Coverage Resources

Medical Coverage

Prescription Resources

Prescription Drug Formulary

Prior Authorization and Step Therapy Criteria

Prescription Drug Coverage

Additional Important Resources

Star Ratings

Other

Provider Appeals

Coverage Policies

Coverage policies are tools to assist in interpreting standard health coverage plan provisions.

Coverage is based on:

  • Medicare national coverage determinations (NCDs) 
  • Local coverage determinations (LCDs) 
  • The member’s applicable Medicare Evidence of Coverage (EOC) and Summary of Benefits (SOB)

In the absence of an applicable national coverage determination, local coverage determinations, or other CMS-published guidance, Sanford Health Plan uses medical policies based on credible scientific evidence published in peer-reviewed medical literature. These Sanford Health Plan coverage summaries apply to Align powered by Sanford Health Plan Medicare Advantage plans.

Sanford Health Plan uses vendor guidelines for certain products to support utilization management review of certain services.

Access MCG care guidelines online using the link below. You will be asked to check the Terms and Conditions box, select Accept and Proceed, and then enter your username and contact information. After completing these steps, you will receive an access code via your preferred method.

Access Coverage Policies

Provider and Pharmacy Directories

Find a Doctor:

Easily search for in-network doctors, clinics and hospital locations near you with our online directory or download a printable version below. 

 

Find a Pharmacy:

We’ve partnered with major and local pharmacies so you never have to travel far. Search our easy-to-use online directory to find a pharmacy near you or download the printable version below.

 

For Align DUALPartnership (HMO D-SNP) Members:

Provider, Facilities and Pharmacy Directory

 

Download our Member Newsletter

Inside each issue of Thriving with Align powered by Sanford Health Plan, you’ll find information about your Medicare Advantage plan and ways to improve your health and well-being.

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Common Coverage Questions

What if I still get health coverage through my employer?

You can keep the health plan you have and enroll in Medicare when you retire.

  • If you keep medical coverage through your job and wait to get Part B, you’ll have eight months from when you retire to add Part B without a penalty. When you’re ready to add Part B coverage, contact your local Social Security office.
  • If you keep getting drug coverage through your job, you won’t pay a penalty if you add Part D later, as long as the coverage you have is considered creditable.

It’s important to talk to your employer or local insurance agent before choosing to stay on your group plan or enroll in Medicare.

In which areas are plans offered?

Align powered by Sanford Health Plan options are available in select counties within Iowa, Minnesota, North Dakota and South Dakota. Your eligibility to enroll in these plans depends on the service area and county where you live.

Browse our eligible counties.

What does my plan cover?

Learn more about your plan coverage:

What should I know about my plan’s pharmacy coverage?

To view a complete summary of your plan’s pharmacy benefits, see your Summary of Benefits document.

Do you qualify for a Low-Income Subsidy (LIS)?
You may be able to get extra help paying for your prescription drug premiums and costs. For more info and to see if you qualify, contact:
Medicare at (800) MEDICARE or (800) 633-4227, TTY (877) 486-2048. Help is available 24/7.

Or the Social Security Administration at (800) 772-1213, TTY (800) 325-0778. Their hours are Monday through Friday from 7 a.m. to 7 p.m.

What are the ratings for these plans?

How do I change or cancel my insurance plan?

To change your plan:
You can enroll in a plan or switch to a new one during the Annual Enrollment Period (AEP). The Centers for Medicare & Medicaid Services (CMS) chooses this annual time period each year. This period is the only time of year when you can make changes to your plan unless you qualify for a Special Enrollment Period (SEP).

For 2022, the AEP is from Oct. 15 through Dec. 7, 2021. If you enroll during this time, your coverage begins on Jan. 1, 2022.

Contact us if you have any questions.

What are my rights and responsibilities upon disenrollment?
If you decide to disenroll from your Align powered by Sanford Health Plan Medicare Advantage plan, you’re ending your membership. Disenrollment can be voluntary (your choice) or involuntary (not your choice). For more information on enrollment or disenrollment, refer to your Evidence of Coverage.

If you decide you want to leave your plan, you can do so for any reason. However, there are limits to when you can leave, how often you can make changes and what type of plan you can join after you leave. Call us for more information.

Sanford Health Plan may disenroll you for these reasons:

  • If you move permanently out of the plan’s service area and do not voluntarily disenroll, or if you live outside the plan’s service area for more than 6 months out of a year
  • If your entitlement to Medicare Part A or Medicare Part B ends
  • If you supply fraudulent information or make any misrepresentations on your enrollment request form that materially affect your eligibility to enroll in the plan
  • If your behavior is disruptive, unruly, abusive or uncooperative to the extent that your membership in your plan seriously impairs our ability to arrange covered services for you or other individuals enrolled in the plan
  • If you knowingly permit abuse or misuse of your Align powered by Sanford Health Plan Medicare Advantage ID card
  • If you fail to pay plan premiums, copayments, coinsurance or other payments required by the plan
  • If the contract between Sanford Health Plan and CMS, which certifies Medicare Advantage plans, is terminated

How do I file a grievance or appeal a coverage decision?

Medicare Advantage (Part C)

Appeals and Grievances:
Call (888) 278-6485, TTY (888) 279-1549.

Our hours are 8:00 a.m. to 8:00 p.m. CST, 7 days a week from October 1 - March 31; and Monday through Friday from April 1 - September 30.

Mail: Mail the form to:
Sanford Health Plan
PO Box 91110
Sioux Falls, SD 57109-1110

Fax: (605) 312-8217

Where can I find an appeal form?
 Appeal form 

Medicare Advantage Part (D)
 To file an appeal or grievance related to Medicare Advantage (Part D), please see section below titled: How do I request a coverage determination or medical exception for a drug?

What is an Appointment of Representative form?
 If a member wants someone who is not already authorized under state law to act for them, the member and that person must sign and date an Appointment of Representative form to give that person legal permission to be an appointed representative.

How do I file a grievance?
 You or your appointed representative can call the grievances phone number to file a grievance.

For more on this process, refer to “What to do if you have a problem or complaint (coverage decisions, appeals, complaints)” in your Evidence of Coverage.

What if I don’t want to file my complaint through Sanford Health Plan?
 You can go directly to medicare.gov or call (800) MEDICARE (633-4227) to file a complaint.

You can also get help with Medicare-related complaints, grievances and information requests from the Medicare Beneficiary Ombudsman (MBO).

Medicare Complaint Form

How do I request a coverage determination or medical exception for a drug?

This form may be sent to us by mail or fax:

Address:
OptumRx Prior Authorization Dept. (844) 403-1028
P.O. Box 2975 
Mission, KS 66201

You may also ask us for a coverage determination by phone at (844) 642-9090 or through the following link www.optumrx.com.

What is the Medicare Part D transition process?

To view the complete Prescription Drug Transition Policy, click here.

What is the Medication Therapy Management program?

Better therapeutic outcomes for members with multiple conditions

Our Medication Therapy Management Program (MTMP) is focused on improving therapeutic outcomes for Medicare Part D members. To qualify for MTMP, a member must meet all of the following criteria:

  • Members must have filled eight or more chronic Part D medications; and
  • Members must have at least three of the following ten chronic conditions
    • Asthma
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Congestive Heart Failure (CHF)
    • Depression
    • Diabetes
    • High Blood Pressure
    • High Cholesterol
    • Osteoporosis
    • Rheumatoid Arthritis
    • HIV
  • Members must be likely to incur 2024 annual costs of $5,330 for all covered chronic Part D medications.

OR

  • Are in a Drug Management Program to help better manage and safely use medications such as opioids and benzodiazepines

Do you meet all of the criteria above? MTMP will help you learn about how to manage the various medications you need to stay healthy.

The success of our MTMP is built upon our proven experience using a wide range of services designed to help members with multiple conditions by:

  • Ensuring they take their medications correctly
  • Improving medication adherence
  • Detecting potentially harmful medication uses or combinations of medications 
  • Educating members and health care providers

Our programs are evidence-based and can integrate both pharmacy and medical data, when available, and are built upon multiple measures that demonstrate positive clinical outcomes for members like you. Pharmacists, physicians and PhDs develop, manage and evaluate the programs for effectiveness.

One-on-one consultations between our clinicians and members are also an important part of our MTMP. Such consultations ensure that members are taking their medications as prescribed by their health care provider.

Comprehensive Medication Review (CMR)

The Centers for Medicare & Medicaid Services (CMS) requires all Part D sponsors to offer an interactive, person-to-person comprehensive medication review (CMR) to all MTM-eligible members as part of MTMP. If you meet the criteria outlined above, you will receive an MTMP Enrollment Mailer or phone call offering our CMR services. A CMR is a review of a member’s medications (including prescription, over-the-counter (OTC), herbal therapies and dietary supplements), which is intended to aid in assessing medication therapy as well as optimizing outcomes. Also, MTMP-eligible members will be included in quarterly targeted medication review (TMR) programs that assess medication profiles for duplicate therapy or drug-disease interaction in which members’ prescribers may receive a member-specific report.

The CMR includes three components:

  1. Review of medications to assess medication use and identify medication-related problems. This may be conducted person-to-person or "behind the scenes" by a qualified provider and/or using computerized, clinical algorithms.
  2. An interactive, person-to-person consultation performed by a qualified provider at least annually to all MTM-eligible members.
  3. An individualized, written summary of the consultation for the member, including but not limited to, a medication list, reconciled medication list, and recommended to-do list for monitoring, education, or self-management.
 

View or download a sample copy of our MTMP Enrollment Mailer
View or download a copy of the Recommended To-Do List
View or download a copy of the Medication List

Do you have unused expired medications and are looking for a safe way to dispose of them? Before you throw them away, here are some things you should know.

Here is how to safely dispose of unused or expired medications before they do harm:

For safety reasons, dispose of unused medications as soon as possible. Here are a few tips for safe disposal:

  • Find a nearby pharmacy or other local resource with a medication take back service.
  • If you cannot get to a drug take back location promptly, or there is none near you:
    • Mix the unused supply with an undesirable substance such as dirt or coffee grounds.
    • Put the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag, then place the sealed container in your trash.
    • Make sure to conceal or remove any personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off to protect your privacy.
    • Place both the sealed container with the mixture and the empty drug containers in the trash.
    • Only flush approved unused or expired medications down the toilet only if indicated on the label, patient information, or no other disposal options are available.

More information on the safe disposal of medications can be found on the United States Department of Health and Human Services website: https://www.hhs.gov/opioids/prevention/safely-dispose-drugs/index.html

Contact OptumRx or your health plan at the number listed on the back of your ID card for more information about our MTMP. If you have any questions about the MTM program, please call the MTM Department at 1-866-352-5305. (TTY users dial 711), Monday - Friday, 8 am to 8 pm CST.

These programs are provided at no additional cost as part of your coverage and are not considered a benefit.

Medicare Advantage Basics

What are some Medicare basics?

What is Original Medicare?
Medicare is the government-run insurance program for those 65 and older or certain people with disabilities or end-stage renal disease (permanent kidney failure).

Medicare has four different parts, which can be mixed and matched through different plans to give you the coverage that’s right for you. They include:

  • Medicare Part A
  • Medicare Part B
  • Medicare Part C (Medicare Advantage)
  • Medicare Part D

What is Medicare Part A?
Medicare Part A, also called hospital insurance, covers:

  • Inpatient hospital stays
  • Skilled nursing facility stays
  • Hospice care
  • Nursing home care
  • Home health care

What is Medicare Part B?
Medicare Part B is also known as medical insurance. It covers certain services from doctors, outpatient care, medical supplies and preventive care. These services fall under Medicare Part B:

  • Physician services
  • Ancillaries (lab work, X-rays, etc.)
  • Therapy (PT, OT, SLP)
  • Clinical research
  • Ambulances
  • Durable medical equipment
  • Mental health care
  • Limited prescription drugs

What is Medicare Advantage?
Medicare Advantage Plans, or Part C plans, are plans offered by private companies like Sanford Health Plan. These plans administer your Original Medicare.

Many plans include prescription drug coverage to combine Medicare Part A, Part B and Part D into one easy package.

What is Medicare Part D?
Medicare Part D is prescription drug coverage. You can buy Part D from insurance companies to go with your Original Medicare coverage or your Medicare Supplement coverage. You could also choose a Medicare Advantage plan that includes Part D prescription drug coverage.

Am I eligible for Medicare?

You’re eligible for Original Medicare, Medicare Part A and Medicare Part B if you fit one of these criteria:

  • Are age 65 or older
  • Are disabled
  • Have end-stage renal disease

Am I eligible for Medicare Advantage?

To be eligible for a Medicare Advantage plan, you must:

  • Have Medicare Parts A and B - Continue to pay your Medicare Part B premium if it’s not paid for under Medicare or by a third party
  • Live in the plan’s service area

When is your next seminar?

Sanford Health Plan offers free educational seminars and wellness events throughout the year.

View All Events

Sanford Health Plan and Sanford Health Plan of Minnesota have HMO and PPO plans with a Medicare contract. Sanford Health Plan D-SNPs have contracts with State Medicaid programs. Sanford Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, or any other classification protected under the law. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.


CMS ID Number: H8385_SHPMAWebsite_PY2025_ND_SD_IA, H3186_SHPMAWebsite_PY2025_MN H8967_DSNPWebsite_PY2025_ND

Last Updated On: 11.01.24 at 10:00 AM