Stanford Select Copay Health Plan

The Stanford Select Copay Health Plan, administered by Aetna, has a nationwide network. Medical care must be received in-network, and most services are covered by a copay. Out-of-network care is only covered in emergencies.

Network

The Stanford Select Copay Health Plan uses the Aetna Select Network, which includes Stanford Health Care (SHC), Sutter Health, including the Palo Alto Medical Foundation (PAMF) network, and University of California San Francisco (UCSF) providers.

Know where to go for care

Preferred Providers

Certain services, such as lab work, imaging, and physical therapy, will have lower copays for preferred in-network providers or facilities (Maximum Savings/Tier 1) than for other in-network or out-of-network providers and facilities (Standard Savings/Tier 2).

View the Aetna Maximum Savings Guide

Aetna formulary for all three plans: Aetna Standard Plan

Outpatient Services

Aetna will help you locate high-quality and cost-effective options for diagnostic services, lab draws, imaging, colonoscopies, and other services. Visit Aetna’s website to compare costs or contact Aetna member services at 833-971-4583.

Advocacy Services and Clinical Care Management

Aetna offers a concierge program to help you maximize your benefits and guide you to the right resources. Clinical care specialists assist you in managing chronic medical conditions, answering questions, and finding the right doctors. Get started at Aetna’s website.

BASICS	Benefit
Overview	The Stanford Select Copay Health Plan requires you to designate a primary care physician (PCP) to coordinate your care. If you do not select a PCP, a PCP will be auto assigned to you based upon your claims history and an available physician based upon your location. The Stanford Select Copay Health Plan uses the Aetna Select nationwide network. You must receive all non-emergency care from in-network providers. You may visit any SHCA network doctor or hospital. Some services require prior authorization from your PCP. There is no benefit if you see a non-network provider, except for emergency care. Group #232361 Plan ID #001

BASICS

Benefit

Overview

The Stanford Select Copay Health Plan requires you to designate a primary care physician (PCP) to coordinate your care. If you do not select a PCP, a PCP will be auto assigned to you based upon your claims history and an available physician based upon your location. The Stanford Select Copay Health Plan uses the Aetna Select nationwide network. You must receive all non-emergency care from in-network providers. You may visit any SHCA network doctor or hospital. Some services require prior authorization from your PCP. There is no benefit if you see a non-network provider, except for emergency care.

Group #232361 Plan ID #001

Referral Requirement	No referral is required to see most specialists. There may be specific cases where a referral is required however (i.e. neurosurgeon).
Prior Authorization Requirement	Prior authorization is required for the following services: Advanced Imaging (CT, MRI, MRA and PET), all electively scheduled inpatient hospital admissions, all elective outpatient procedures (example – endoscopic procedures, arthroscopic procedures, epidural steroid injections, etc.), other procedures and services as defined on the precertification requirement list.
Deductible	No deductible
Out-of-Pocket Maximum	$3,500 per individual/$7,000 familyA single out-of-pocket maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the out-of-pocket maximum is met.)

PREVENTIVE CARE	Benefit
Physical Exams for Adults	100%
Physical Exams for Children	100%
Pap Smears	100% (as part of the office visit)
Immunizations	100% (this includes Covid and Flu Shots) Travel immunizations are covered within the network.
Well-Woman Visits	100%

MEDICAL SERVICES	Benefit
Blood work and basic imaging (X-Rays and Ultrasounds)	Preferred in-network: no charge Other in-network: $50 copay Out-of-network: not covered
Imaging (CT/PET Scans, MRIs)	Preferred in-network: $50 copay Other in-network: $500 copay Out-of-network: not covered
Rehab – Physical Therapy	Preferred in-network: $30 copay Other in-network: $75 copay Out-of-network: not covered
Primary Care	In-network: $30 copay Out-of-network: not covered
Specialty Care	In-network: $60 copay Out-of-network: not covered
Urgent Care	In-network: $75 copay Out-of-network: not covered
Emergency Care	In-network: $200 copay (waived if admitted) Out-of-network: $200 copay (waived if admitted)
PRESCRIPTION DRUGS	Benefit
Pharmacy (Retail)	$10 generic; $40 brand name; $100 non-formulary — up to a 30-day supplyOut-of-network Pharmacy: not covered
Mail-Order Drug Program	$20 generic; $100 brand name; $250 non-formulary — up to a 90-day supplyMust use Aetna mail-order service
Birth Control Pills	Included in prescription drug benefit

Tiered Services: Maximum Savings/Tier 1. Standard Savings/Tier 2.

Labs	Tier 1: 100% no deductible, no copay Tier 2: 100% no deductible after $50 copay
Imaging	Tier 1: 100% no deductible after $50 copay Tier 2: 100% no deductible after $500 copay
Physical Therapy	Tier 1: $30 copay Tier 2: 100% no deductible after $60 copay

Learn more about how you can reduce your costs when accessing these services on the Aetna Maximum Savings Guide.

REPRODUCTIVE HEALTH	Benefit
Abortion services	The Stanford Select Copay Health Plan provides abortion services as they remain protected under California state law. As this is a network-only plan, members in states that ban or restrict access to abortion services may have to travel to a network location if one is not available within 100 miles of their ZIP code. Travel and lodging will be covered. The copay for pregnancy termination services is $125 and, if hospitalization is required, the $150 hospital copay would be applied as well.

REPRODUCTIVE HEALTH

Benefit

Abortion services

The Stanford Select Copay Health Plan provides abortion services as they remain protected under California state law. As this is a network-only plan, members in states that ban or restrict access to abortion services may have to travel to a network location if one is not available within 100 miles of their ZIP code. Travel and lodging will be covered. The copay for pregnancy termination services is $125 and, if hospitalization is required, the $150 hospital copay would be applied as well.

Traveling Outside the U.S.

Effective June 15, 2024 everyone enrolled in the Stanford Select Copay Health Plan has international benefit coverage through Aetna International. This benefit includes a $0 deductible and 100% coinsurance for all medically necessary services received outside the United States during a vacation or a short-term business trip.

The international component of the Copay plan includes 24/7 customer service to assist you at any time while you are travelling overseas. You can contact Aetna’s international customer service team telephonically or via the member portal:

· AetnaInternational.com

· +1-800-231-7729

The Aetna International member portal is linked to AetnaHealth so you will not need to create a separate User ID and Password. Log into AetnaHealth to access an electronic version of your international medical card which can be uploaded to your cell phone (Ios and Android).

You can receive medical services anywhere around the world. Aetna International has an expansive network of hospitals and providers where you can receive services on a cashless basis. This means that when you receive care from a participating facility or provider, the bill for the service is sent to Aetna directly rather than you, saving you the burden of submitting the claim for reimbursement. You will need to contact Aetna International within 3 days of any outpatient services so Aetna can establish this service for you. Aetna International will secure this arrangement the same day for any emergency services.

You will see the network of international providers at AetnaInternational.com.

Aetna International has an easy process if you have to submit a claim for reimbursement:

· Log into the member portal.

· Go to AetnaInternational.com.

· Click on “My Claims” and select “New Claim.”

· Complete the online form.

· Upload a picture of your receipts.

· Click “Submit”.

You will receive your reimbursement via a paper check of electronically deposited into your bank account.

When you’re outside the United States and have questions about any health event, you can call Aetna International and speak with a member of their care management team. Their clinicians are available 24/7 and can help you with:

· Finding doctors/hospitals where you are

· Providing culturally appropriate care recommendations

· Coordinating and supervising emergency services including evacuation (if needed)

· Support in multiple languages

· Getting medical devices or prescription medications

Aetna provides “Emergency Care” coverage anywhere you may experience an emergency that is life-threatening in nature. Contact Aetna to locate an approved facility for non-emergency/non-life-threatening medical services. Pre-authorization may be required for certain services. You can log into your Aetna account and download a digital ID card at MyAetnaWebsite.com. This card will be different than your Stanford Select Copay Plan card used for domestic US benefits.

Learn more about traveling outside the U.S.

Plan Information and Resources for the Stanford Select Copay Health Plan

2024 Plan Documents

Stanford Select Copay Health Plan Summary Plan Description (EOC)

An SPD or EOC is the official, detailed plan document for each plan outlining information about eligibility; costs and cost-sharing; included and excluded services; claims process; procedures for filing grievances, complaints and appeals.