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Comparison Tool

2019 Plans & Contribution Rates



Medical Plans

Compare medical plans available for each of these roles:

Dental Plans

Compare dental plans available for each of these roles:

Vision Plan

Compare vision plans available for each of these roles:

Full Plan Costs

Compare the premium costs for each of these roles:

Active Employees

Retirees

SELECT THE PLAN(S) TO COMPARE:
SELECT THE PLAN(S) TO COMPARE:
SELECT THE PLAN(S) TO COMPARE:
Active employees may select one of two offered dental plans.
Stanford offers one dental plan for all eligible retirees.

Delta Dental Basic PPO Plan #3365 - 2019

Basics
Full-Time Employee * Contribution Per Pay Period: 

Employee Only: $0.00
Employee & Spouse/Partner: $0.00
Employee & Children: $0.00
Employee & Family: $0.00

Part-Time Employee * Contribution Per Pay Period: 

Employee Only: $8.87
Employee & Spouse/Partner: $18.63
Employee & Children: $15.96
Employee & Family: $25.71

Overview: 

Delta Dental PPO is the dentist network for this plan.

This plan pays most benefits at a percentage.

The benefit level does not depend on what providers you use.

You are encouraged to obtain a predetermination of benefits from Delta for services greater than $300, or for crowns or bridges.

Deductible: 

$50 per individual $150 per family

Coinsurance: 
  • Preventive and diagnostic: 100% of usual & customary charges
  • Basic procedures: 80% of usual & customary charges
  • Major restorative procedures: 50% of usual & customary charges

You are responsible for amounts not covered by the dental plan.

Annual maximum: 

$1,000 per individual

Lifetime maximum: 

Orthodontia is not covered

Preventive Type of Care
Cleanings: 

Preventive and diagnostic service:
100% (deductible waived)

Balance billing by a Non-Network dentist may apply. You are responsible for these charges.

Plan allows up to three cleanings/year. The third cleaning applies to certain conditions including diabetics, pregnancy, and those requiring periodontal maintenance.

Fluoride treatments: 

Preventive and diagnostic service:
100% (deductible waived)

Balance billing by your dentist may apply. You are responsible for these charges.

Routine exams: 

Preventive and diagnostic service:
100% (deductible waived)

Balance billing by your dentist may apply. You are responsible for these charges.

Sealants: 

Basic procedures service:
80% after deductible

X-rays: 

Preventive and diagnostic service:
100% (deductible waived)
Balance billing by your dentist may apply. You are responsible for these charges.

Orthodontic Services
Orthodontia: 

Not covered

Retainers: 

Not covered

Other Services (A-E)
Anesthesia: 

Basic procedures service:
80% after deductible

Bridges: 

Major Restorative procedures service:
50% after deductible

Crown: 

Major Restorative procedures service:
50% after deductible

Dentures: 

Major Restorative procedures service:
50% after deductible

Extractions: 

Basic procedures service:
80% after deductible

Other Services (F-O)
Fillings: 

Basic procedures service:
80% after deductible

Gingivectomy: 

Basic procedures service:
80% after deductible

Gold restorations: 

(Inlays & Onlays only) Major Restorative procedures service:
50% after deductible

Implants: 

Not covered

Inlays: 

Major Restorative procedures service:
50% after deductible

Onlays: 

Major Restorative procedures service:
50% after deductible

Oral surgery: 

Basic procedures service:
80% after deductible

Other Services (P-Z)
Periodontal surgery: 

Basic procedures service:
80% after deductible

Prescription drugs: 

Not covered

Root canals: 

Basic procedures service:
80% after deductible

Space maintainers: 

Preventive and diagnostic service:
100% (deductible waived)
Balance billing by your dentist may apply. You are responsible for these charges.

Splinting: 

Not covered

TMJ (Temporomandibular joint syndrome): 

Not covered

Delta Dental PPO Plan #1149 - 2019

Basics
Overview: 

This plan pays in-network benefits when your care is either provided or authorized by your Delta Dental PPO network dentist.

If your network dentist does not provide or authorize your care, the charges are considered out-of-network.

You are encouraged to obtain a predetermination of benefits from Delta for services greater than $300, or for crowns or bridges.

Deductible: 

Network: $0 per individual/$0 per family
Non-network: $50 per individual/$150 family

Coinsurance: 

   Network:

  • - Preventive and diagnostic: 100% of the negotiated rate
  • - Basic procedures: 80% of the negotiated rate
  • - Major restorative procedures: 50% of the negotiated rate

Non-Network:

  • All services: 50% of usual & customary charges
Annual maximum: 

Network & Non-Network Combined: $1,000 per individual

Preventive Type of Care
Cleanings: 

Preventive and Diagnostic service:
Network: 100%
Non-Network: 50% (deductible waived)
Plan allows up to 2 cleanings a year.

Fluoride treatments: 

Preventive and Diagnostic service:
Network: 100%
Non-Network: 50% (deductible waived)

Routine exams: 

Preventive and Diagnostic service:
Network: 100%
Non-Network: 50% (deductible waived)

Sealants: 

Basic procedures service:
Network: 80%
Non-Network: 50% after deductible

X-rays: 

Preventive and Diagnostic service:
Network: 100%
Non-Network: 50% (deductible waived)

Other Services (A-E)
Anesthesia: 

Basic procedures service:
Network: 80%
Non-Network: 50% after deductible

Bridges: 

Major Restorative procedures service:
Network: 50%
Non-Network: 50% after deductible

Crown: 

Major Restorative procedures service:
Network: 50%
Non-Network: 50% after deductible

Dentures: 

Major Restorative procedures service:
Network: 50%
Non-Network: 50% after deductible

Extractions: 

Basic procedures service:
Network: 80%
Non-Network: 50% after deductible

Other Services (F-O)
Fillings: 

Basic procedures service:
Network: 80%
Non-Network: 50% after deductible

Gingivectomy: 

Basic procedures service:
Network: 80%
Non-Network: 50% after deductible

Gold restorations: 

(Inlays & Onlays only) Major Restorative procedures service:
Network: 50%
Non-Network: 50% after deductible

Implants: 

Major Restorative procedures service:
Network: 50%
Non-Network: 50% after deductible

Inlays: 

Major Restorative procedures service:
Network: 50%
Non-Network: 50% after deductible

Onlays: 

Major Restorative procedures service:
Network: 50%
Non-Network: 50% after deductible

Oral surgery: 

Basic procedures service:
Network: 80%
Non-Network: 50% after deductible

Other Services (P-Z)
Periodontal surgery: 

Basic procedures service:
Network: 80%
Non-Network: 50% after deductible

Prescription drugs: 

Not covered

Root canals: 

Basic procedures service:
Network: 80%
Non-Network: 50% after deductible

Space maintainers: 

Preventive and Diagnostic service:
Network: 100%
Non-Network: 50% (deductible waived)

Splinting: 

Not covered

TMJ (Temporomandibular joint syndrome): 

Not covered

Delta Dental Enhanced PPO Plan #3366 - 2019

Basics
Full-Time Employee * Contribution Per Pay Period: 

Employee Only: $11.08
Employee & Spouse/Partner: $23.20
Employee & Children: $19.92
Employee & Family: $32.08

Part-Time Employee * Contribution Per Pay Period: 

Employee Only: $19.99
Employee & Spouse/Partner: $41.98
Employee & Children: $35.96
Employee & Family: $57.93

Overview: 

This plan pays in-network benefits when your care is either provided or authorized by your Delta Dental PPO network dentist.

If your network dentist does not provide or authorize your care, the charges are considered out-of-network.

You are encouraged to obtain a predetermination of benefits from Delta for services greater than $300, or for crowns or bridges.

Deductible: 

Network: $0 per individual/$0 per family
Non-Network: $50 per individual/$150 family

Coinsurance: 

Network:

  • Preventive and diagnostic: 100% of the negotiated rate
  • Basic procedures: 80% of the negotiated rate
  • Major restorative procedures: 50% of the negotiated rate

Non-Network:

  • Preventive and diagnostic: 80% of usual & customary charges
  • Basic procedures: 60% of usual & customary charges
  • Major restorative procedures: 50% of usual & customary charges
Annual maximum: 

Network: $3,000 per individual
Non-Network: $1,500 per individual

Lifetime maximum: 

Orthodontia only: $1,500

Preventive Type of Care
Cleanings: 

Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 80% (deductible waived)

Plan allows up to three cleanings/year. The third cleaning applies to certain conditions including diabetics, pregnancy, those requiring periodontal maintenance and those in an active orthodontic treatment plan.

Fluoride treatments: 

Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 80% (deductible waived)

Routine exams: 

Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 80% (deductible waived)

Sealants: 

Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network Provider: 60% after deductible

X-rays: 

Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 80% (deductible waived)

Orthodontic Services
Orthodontia: 

Network: 50% of Delta's approved fee
Non-Network: 50% of Delta's approved fee

Combined Orthodontia lifetime maximum benefit of $1,500. Payment is split over two plan years at $750 per year and you must be enrolled in the Enhanced plan both years.

Retainers: 

(Covered under the Orthodontia benefit)

PPO Network Provider: 50% of Delta's approved fee
Premier or Non-Network: 50% of Delta's approved fee

Other Services (A-E)
Anesthesia: 

Basic procedures service:
PPO Network Providers: 80%
Premier or Non-Network: 60% after deductible

Bridges: 

Major Restorative procedures service:
PPO Network Providers: 50%
Premier or Non-Network: 50% after deductible

Crown: 

Major Restorative procedures service:
PPO Network Providers: 50%
Premier or Non-Network: 50% after deductible

Dentures: 

Major Restorative procedures service:
PPO Network Providers: 50%
Premier or Non-Network: 50% after deductible

Extractions: 

Basic procedures service:
PPO Network Providers: 80%
Premier or Non-Network: 60% after deductible

Other Services (F-O)
Fillings: 

Basic procedures service:
PPO Network Providers: 80%
Premier or Non-Network: 60% after deductible

Gingivectomy: 

Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible

Gold restorations: 

(Inlays & Onlays only) Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible

Implants: 

Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible

Inlays: 

Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible

Onlays: 

Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible

Oral surgery: 

Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible

Other Services (P-Z)
Periodontal surgery: 

Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible

Prescription drugs: 

Not covered

Root canals: 

Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible

Space maintainers: 

Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 80% (deductible waived)

Splinting: 

Not covered

TMJ (Temporomandibular joint syndrome): 

Not covered

Stanford HealthCare Alliance Plan - Group # 868025 - 2019

Ratings
National Committee For Quality Assurance (NCQA)
Up to four stars are given for each of the following criteria:
Overall Accredition Status: 
Not reported by NCQA
Access & Services: 
4
Qualified Providers: 
0
Staying Healthy: 
0
Getting Better: 
0
Living With Illness: 
0
Basics

The Stanford HealthCare Alliance ACO plan requires you designate a primary care provider to coordinate all of your care. You may visit any Stanford HealthCare Alliance network doctor or hospital. Some services require prior authorization from your primary care physician. 

There is no benefit if you see a Non-Network provider, except for emergency care or when clinically appropriate and prior authorized by Stanford HealthCare Alliance.

Description: 
SHCA
Full-Time Employee * Contribution Per Pay Period: 

Employee Only: $30.00
Employee & Spouse/Partner: $232.32
Employee & Children: $201.78
Employee & Family: $301.78

Part-Time Employee * Contribution Per Pay Period: 

Employee Only: $330.74
Employee & Spouse/Partner: $764.91
Employee & Children: $655.65
Employee & Family: $1,056.32

Pre-Authorization Requirement: 

Pre-authorization from your primary care provider is required for the following services: Advanced Imaging (CT, MRI, MRA and PET); all electively scheduled inpatient admissions; all elective outpatient procedures (example- endoscopic procedures, arthroscopic procedures, epidural steroid injections, etc.); physical therapy; durable medical equipment; speech therapy.

PENALTY for not pre-authorizing: the services will be considered not covered by the plan and the member is responsible for the full amount of the service.

Care Management: 

Participation in care management required for certain conditions and diseases.

Deductible: 

No deductible

Office co-pay: 

$30 co-pay primary/$75 co-pay specialist

Coinsurance: 

100% after applicable co-pays

Out-of-Pocket Maximum: 

$3,500 per individual/$7,000 family

A 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.)

Overall Lifetime Maximum: 

No maximum

Maternity
Maternity Hospital Stay: 

$150 co-pay per admission

Baby's First Exam: 

100%

Birthing Centers: 

$150 co-pay per admission

Midwives: 

100%

If the midwife is part of the Stanford HealthCare Alliance network.

Prenatal Visits: 

100%

Doctor Delivery Charge: 

100%

Pregnancy Termination: 

$125 co-pay

If hospitalized, the Hospital Stay co-payment will also apply.

Mental Health/Substance Abuse
Mental Health: 

Stanford HealthCare Alliance must approve mental health care.

INPATIENT CARE
$150 co-pay per admission

ROUTINE OUTPATIENT CARE
[no visit limit]
Network: $30 co-pay per visit
Non-Network: 80% of billed charges (up to $300 maximum allowed charges) for professional services only.

The maximum allowed amount will not exceed $300 for each office visit.  For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.

Autism: 

Behavioral health treatment (BHT) consists of professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorders or autism. Prior authorization for BHT or ABA services is required. Plan mental health cost sharing applies.

Substance Abuse: 

Pre-certification is required by you or your provider.

INPATIENT CARE
$150 co-pay per admission

ROUTINE OUTPATIENT CARE
[no visit limit]
Network: $30 co-pay per visit
Non-Network: 80% of billed charges (up to $300 maximum allowed charges) for professional services only.

The maximum allowed amount will not exceed $300 for each office visit.  For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.

Other Services (A-D)
Acupuncture: 

$30 co-pay

Up to 20 visits per year

Network providers only

Allergy Tests: 

100%

Office co-pay may apply.

Allergy Treatment: 

100%

Office co-pay may apply.

Alternative Medicine: 

Not covered

Ambulance charges: 

100% after $50 co-pay

CAT Scans: 

100% **Pre authorization requirement

Chiropractors: 

$30 co-pay

Up to 20 visits per year

Network providers only

Christian Science Practitioners: 

Not covered

Cosmetic Surgery: 

Not covered

Dental Treatment: 

Coverage limited to certain conditions only. Contact Stanford Health Care Alliance member services for more information.

Other Services (E-N)
Emergency Room: 

$200 co-pay (waived if admitted)

Urgent Care: 

Office visit co-payment, specialist visit co-payment, or Emergency Room co-payment, depending on the facility.

Hearing Care: 

Exam $75 co-pay

Hearing aids not covered

Home Health Care: 

100%

Hospice Care: 

100%

Hospital Stay: 

Pre-Certification required by you or your provider. $150 co-pay per admission

Infertility Treatment: 

Network: 50% of Stanford Health Care Alliance allowed charges for professional and diagnostic services; limited to three cycles of intrauterine insemination (IUI).

In Vitro, GIFT, and ZIFT: Not covered

Fertility drugs: see Pharmacy

Laboratory Charges: 

100%

Magnetic resonance imaging - MRI: 

100% **pre authorization requirement

Durable Medical Equipment: 

100% **pre authorization requirement

Other Services (O-Z)
Occupational Therapy: 

$40 co-pay

Organ Transplants: 

Contact Stanford Health Care Alliance member services for information on transplant coverage benefits

Skilled Nursing: 

$150 co-pay per admission

Up to 100 days per calendar year

Physical Therapy: 

$40 co-pay **pre authorization requirement

Surgery : Physician Services: 

INPATIENT
Covered under hospital co-pay

OUTPATIENT
Office visit co-pay may apply

Surgery : Facility Charges: 

INPATIENT
$150 co-pay per admission

OUTPATIENT
$150 co-pay per surgery

Speech Therapy: 

$40 co-pay **pre authorization requirement

Tubal Ligation: 

INPATIENT
$150 co-pay per admission

OUTPATIENT
$150 co-pay per procedure

[Facility co-payments only; physician fees also apply]

Vasectomy: 

$75 co-pay

[when performed in the physician office]

X-rays: 

100%

Prescription Drugs
Pharmacy (Retail): 

Stanford HealthCare Alliance uses the Aetna Network pharmacies: $10 generic; $40 brand name; $100 non-formulary -- up to a 30-day supply

Non-Network pharmacy: Member pays co-payment plus 25% of billed charges

Fertility drugs covered at 50% (deductible does not apply); max benefit of $5,000 per lifetime

Mail order drug program: 

$20 generic; $80 brand name; $200 non-formulary -- up to a 90-day supply

Must use Aetna mail-order service

Birth Control Pills: 

Included in Prescription Drug benefit

Preventive Care
Physical exams for adults: 

100%

Physical exams for children: 

100%

Pap smears: 

100%

[as part of the office visit]

Mammograms: 

100%

Immunizations: 

100%

Travel immunizations not covered.

Prostate Specific Antigen test - PSA: 

100%

Well-woman visits: 

100%

Vision care: 

$75 co-pay

Limited to screen and refraction exams only

Stanford HealthCare Alliance Plan - Group # 868025 - 2019

Ratings
National Committee For Quality Assurance (NCQA)
Up to four stars are given for each of the following criteria:
Overall Accredition Status: 
Not reported by NCQA
Access & Services: 
4
Qualified Providers: 
0
Staying Healthy: 
0
Getting Better: 
0
Living With Illness: 
0
Basics

The Stanford HealthCare Alliance ACO plan requires you designate a primary care provider to coordinate all of your care. You may visit any Stanford HealthCare Alliance network doctor or hospital. Some services require prior authorization from your primary care physician. 

There is no benefit if you see a Non-Network provider, except for emergency care or when clinically appropriate and prior authorized by Stanford HealthCare Alliance.

Description: 
SHCA
Full-Time Employee * Contribution Per Pay Period: 

Employee Only: $30.00
Employee & Spouse/Partner: $232.32
Employee & Children: $201.78
Employee & Family: $301.78

Part-Time Employee * Contribution Per Pay Period: 

Employee Only: $330.74
Employee & Spouse/Partner: $764.91
Employee & Children: $655.65
Employee & Family: $1,056.32

Pre-Authorization Requirement: 

Pre-authorization from your primary care provider is required for the following services: Advanced Imaging (CT, MRI, MRA and PET); all electively scheduled inpatient admissions; all elective outpatient procedures (example- endoscopic procedures, arthroscopic procedures, epidural steroid injections, etc.); physical therapy; durable medical equipment; speech therapy.

PENALTY for not pre-authorizing: the services will be considered not covered by the plan and the member is responsible for the full amount of the service.

Care Management: 

Participation in care management required for certain conditions and diseases.

Deductible: 

No deductible

Office co-pay: 

$30 co-pay primary/$75 co-pay specialist

Coinsurance: 

100% after applicable co-pays

Out-of-Pocket Maximum: 

$3,500 per individual/$7,000 family

A 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.)

Overall Lifetime Maximum: 

No maximum

Maternity
Maternity Hospital Stay: 

$150 co-pay per admission

Baby's First Exam: 

100%

Birthing Centers: 

$150 co-pay per admission

Midwives: 

100%

If the midwife is part of the Stanford HealthCare Alliance network.

Prenatal Visits: 

100%

Doctor Delivery Charge: 

100%

Pregnancy Termination: 

$125 co-pay

If hospitalized, the Hospital Stay co-payment will also apply.

Mental Health/Substance Abuse
Mental Health: 

Stanford HealthCare Alliance must approve mental health care.

INPATIENT CARE
$150 co-pay per admission

ROUTINE OUTPATIENT CARE
[no visit limit]
Network: $30 co-pay per visit
Non-Network: 80% of billed charges (up to $300 maximum allowed charges) for professional services only.

The maximum allowed amount will not exceed $300 for each office visit.  For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.

Autism: 

Behavioral health treatment (BHT) consists of professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorders or autism. Prior authorization for BHT or ABA services is required. Plan mental health cost sharing applies.

Substance Abuse: 

Pre-certification is required by you or your provider.

INPATIENT CARE
$150 co-pay per admission

ROUTINE OUTPATIENT CARE
[no visit limit]
Network: $30 co-pay per visit
Non-Network: 80% of billed charges (up to $300 maximum allowed charges) for professional services only.

The maximum allowed amount will not exceed $300 for each office visit.  For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.

Other Services (A-D)
Acupuncture: 

$30 co-pay

Up to 20 visits per year

Network providers only

Allergy Tests: 

100%

Office co-pay may apply.

Allergy Treatment: 

100%

Office co-pay may apply.

Alternative Medicine: 

Not covered

Ambulance charges: 

100% after $50 co-pay

CAT Scans: 

100% **Pre authorization requirement

Chiropractors: 

$30 co-pay

Up to 20 visits per year

Network providers only

Christian Science Practitioners: 

Not covered

Cosmetic Surgery: 

Not covered

Dental Treatment: 

Coverage limited to certain conditions only. Contact Stanford Health Care Alliance member services for more information.

Other Services (E-N)
Emergency Room: 

$200 co-pay (waived if admitted)

Urgent Care: 

Office visit co-payment, specialist visit co-payment, or Emergency Room co-payment, depending on the facility.

Hearing Care: 

Exam $75 co-pay

Hearing aids not covered

Home Health Care: 

100%

Hospice Care: 

100%

Hospital Stay: 

Pre-Certification required by you or your provider. $150 co-pay per admission

Infertility Treatment: 

Network: 50% of Stanford Health Care Alliance allowed charges for professional and diagnostic services; limited to three cycles of intrauterine insemination (IUI).

In Vitro, GIFT, and ZIFT: Not covered

Fertility drugs: see Pharmacy

Laboratory Charges: 

100%

Magnetic resonance imaging - MRI: 

100% **pre authorization requirement

Durable Medical Equipment: 

100% **pre authorization requirement

Other Services (O-Z)
Occupational Therapy: 

$40 co-pay

Organ Transplants: 

Contact Stanford Health Care Alliance member services for information on transplant coverage benefits

Skilled Nursing: 

$150 co-pay per admission

Up to 100 days per calendar year

Physical Therapy: 

$40 co-pay **pre authorization requirement

Surgery : Physician Services: 

INPATIENT
Covered under hospital co-pay

OUTPATIENT
Office visit co-pay may apply

Surgery : Facility Charges: 

INPATIENT
$150 co-pay per admission

OUTPATIENT
$150 co-pay per surgery

Speech Therapy: 

$40 co-pay **pre authorization requirement

Tubal Ligation: 

INPATIENT
$150 co-pay per admission

OUTPATIENT
$150 co-pay per procedure

[Facility co-payments only; physician fees also apply]

Vasectomy: 

$75 co-pay

[when performed in the physician office]

X-rays: 

100%

Prescription Drugs
Pharmacy (Retail): 

Stanford HealthCare Alliance uses the Aetna Network pharmacies: $10 generic; $40 brand name; $100 non-formulary -- up to a 30-day supply

Non-Network pharmacy: Member pays co-payment plus 25% of billed charges

Fertility drugs covered at 50% (deductible does not apply); max benefit of $5,000 per lifetime

Mail order drug program: 

$20 generic; $80 brand name; $200 non-formulary -- up to a 90-day supply

Must use Aetna mail-order service

Birth Control Pills: 

Included in Prescription Drug benefit

Preventive Care
Physical exams for adults: 

100%

Physical exams for children: 

100%

Pap smears: 

100%

[as part of the office visit]

Mammograms: 

100%

Immunizations: 

100%

Travel immunizations not covered.

Prostate Specific Antigen test - PSA: 

100%

Well-woman visits: 

100%

Vision care: 

$75 co-pay

Limited to screen and refraction exams only