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Stanford Health Care Alliance

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Stanford Health Care Alliance (SHCA) is a select network health plan in which Stanford Health Care physicians and affiliated providers in multiple specialties take responsibility for working together to carefully coordinate and deliver your care.

View plan information and resources for SHCA

BASICS

Overview

The SHCA plan requires you to designate a primary care provider (PCP) to coordinate your care. While Aetna provides administrative support for the SHCA plan, members do not access the Aetna network. SHCA is a separate, regional network of providers and facilities in the Bay Area.

You may visit any SHCA network doctor or hospital. Check the SHCA website for a list of in-network providers. Some services require prior authorization from your PCP.

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

Group #868025

Referral Requirement

Visits to a specialist require a referral from your designated PCP.  This includes any specialist you are currently seeing for ongoing care or for new patient visits.  Visits to a specialist without a PCP referral may be denied due to lack of referral.  Exception:  Well-woman exams with an OB/GYN do not require a referral.

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 pre-certification requirement list.

Office copay

$30 copay primary/$75 copay specialist

Deductible

No deductible

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.)

PREVENTATIVE CARE

Physical exams for adults

100%

Physical exams for children

100%

Pap smears

100% (as part of the office visit)

Immunizations

100%

Travel immunizations not covered.

Well-woman visits

100%
PRESCRIPTION DRUGS

Pharmacy (Retail)

SHCA 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

REPRODUCTIVE HEALTH

Abortion services

Stanford Healthcare provides abortion services as they remain protected under California state law.  As this is a network-only plan, members do not need to use travel and lodging benefits while accessing abortion services. The co-payment for pregnancy termination services is $125 and if hospitalization is required the $150 hospital co-payment would be applied as well.

Traveling Outside the U.S.

If you are enrolled in the SHCA plan, SHCA provides services in the greater Bay Area only. If you choose to remain in SHCA, you receive no coverage for routine services outside the service area.

SHCA provides “Emergency Care” coverage anywhere you may experience an emergency that is life-threatening in nature. Contact SHCA to locate an approved facility for non-emergency/non-life-threatening medical services. 

To learn more about SHCA Emergency Care benefits:

  • Call SHCA Member Care Services at 855-345-SHCA (7422)
  • If you need to file a claim for emergency care received while overseas, contact SHCA to have an international claim form sent to you.