Skip to main content Skip to secondary navigation

2024 Stanford Select Copay Health Plan - Control #: 232361 Plan #001

Basics

Full-Time Employee * Contribution Per Pay Period

Employee Only $62.70
Employee & Spouse/Registered Domestic Partner $400.58
Employee & Child(ren) $347.92
Employee & Family $520.35

Part-Time Employee * Contribution Per Pay Period

Employee Only $504.88
Employee & Spouse/Registered Domestic Partner $1,152.69
Employee & Child(ren) $988.02
Employee & Family $1,591.81

Lifetime maximum

No overall healthcare lifetime maximum, but there is a lifetime max for fertility drugs. See below.

Plan Year

2024

Pre-Authorization Requirement

Pre-authorization required for all hospital stays and certain outpatient procedures.

Pre-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.

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.

Offered To

Employees

Care Management

Participation in care management is optional.

Our Aetna One Advisor program takes a comprehensive population health approach to care management. Our multidisciplinary team of nurses, behavioral health clinicians, health coaches, dietitians, pharmacists, and customer services representatives help members live better with illness, recover from acute conditions, and have a seamless healthcare experience.

Body/Description

The Stanford Select Copay Health Plan requires you designate a primary care provider to coordinate all of your care. You may visit any Aetna network doctor or hospital.

There is no benefit if you see a Non-Network provider, except for emergency care or when clinically appropriate and prior authorized by Aetna and outpatient mental health office visits (see Mental Health section).

This document is a summary. Please refer to the plan Evidence of Coverage (EOC) for more details.

Coinsurance

100% after applicable copays

Office co-pay

$30 copay primary/$60 copay specialist

Deductible

No deductible

Benefit Type

Medical

Annual 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.) There is no benefit if you see a Non-Network provider, except for outpatient professional mental health and substance abuse care, emergency care, or when clinically appropriate and prior authorized.

X-rays

Maximum Savings/Tier 1: 100% no deductible no copay
Standard Savings/Tier 2: 100% no deductible after $50 copay

Maternity Hospital Stay

$200 copay per admission

Baby's First Exam

100%

Birthing Centers

100%
If the birthing center is part of the Aetna network

Midwives

100%
If the midwife is part of the Aetna network

Prenatal Visits

100%

Doctor Delivery Charge

100%

Reproductive Health

$125 copay

If hospitalized, the $200 Hospital Stay copay will also apply.

If services are not available within 100 miles of the member home ZIP code travel expenses (airfare, mileage, rental car, lodging, and meals) will be reimbursable after the deductible up to $10,000 per year.

Mental Health

Inpatient Care:
Pre-Certification is required by you or your provider.
$200 copay per admission

Outpatient Therapy Visit
[no visit limit]
Network: $30 copay 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.
If the out-of-pocket maximum is reached, then the benefit will be covered at 100% (up to $300 maximum allowed charge per visit) for that calendar year.

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

Inpatient Care:
Pre-Certification is required by you or your provider.
$200 copay per admission

Outpatient Therapy Visit
[no visit limit]
Network: $30 copay 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.
If the out-of-pocket maximum is reached, then the benefit will be covered at 100% (up to $300 maximum allowed charge per visit) for that calendar year.

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 (if medically approved)

CT Scans

**Pre-authorization required.
Maximum Savings/Tier 1: 100% no deductible after a $50 copay
Standard Savings/Tier 2: 100% no deductible after $500 copay

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 Aetna for more information.

Emergency Room

$200 co-pay (waived if admitted)

Urgent Care

$75 co-pay

Hearing Care

Preventive Exam: 100% as part of preventive care

Non-Routine Exam $60 copay

Hearing aids not covered

Home Health Care

100%

Hospice Care

100%

Hospital Stay

Pre-Certification required by you or your provider. $200 copay per admission

Infertility Treatment

"Standard Base Benefit: Covers the diagnosis and treatment of underlying cause. Cost share is based upon the type of service and place of service rendered (only covered for in-network)

Comprehensive Infertility Services (Artificial Insemination and Ovulation Induction): Network: 50% of billed charges

Advanced Reproductive Technology (ART), which includes In Vitro Fertilization (IVF), GIFT, ZIFT, Cryo-preserved embryo transfers: Covered at 50% of billed charges for up to 3 cycles per lifetime.

Cryopreservation of eggs, embryos and sperm (actual service to freeze what is retrieved from the fertility preservation IVF cycle). This is limited to 3 cycles per lifetime (as stated above) and thawing and storage up to 3 years of eggs, embryos and sperm. This includes iatrogenic and elective fertility.

Rx: Fertility drugs Max benefit of $10,000 per lifetime. (Covers both oral and injectable drugs). Member would be responsible for any fertility drugs over the $10,000 fertility drugs lifetime maximum and that would be an additional out of pocket expense.

*Artificial insemination and ovulation induction are covered regardless of partner status and without a diagnosis of infertility. FSH level - not required. Elective/Social Fertility."

Laboratory Charges

Maximum Savings/Tier 1: 100%, no deductible, no copay
Standard Savings/Tier 2: 100%, no deductible after $50 copay

Magnetic resonance imaging - MRI

**Pre-authorization required
Maximum Savings/Tier 1: 100%, no deductible after $50 copay
Standard Savings/Tier 2: 100%, no deductible after $500 copay

Durable Medical Equipment

100% **pre authorization may apply

Occupational Therapy

$40 copay

Organ Transplants

Contact Aetna member services for information on transplant coverage benefits

Skilled Nursing

$200 copay per admission
Up to 100 days per calendar year
Pre-Certification required.

Physical Therapy

Maximum Savings/Tier 1: $30 copay.
Standard Savings/Tier 2: 100% no deductible after $60 copay.

Prosthetic & Orthotic Devices

Contact the plan for details.

Surgery : Physician Services

INPATIENT
Covered under hospital copay

OUTPATIENT
Office visit copay may apply

Surgery : Facility Charges

INPATIENT
$200 co-pay per admission
OUTPATIENT
$200 co-pay per surgery

Speech Therapy

$40 copay

Tubal Ligation

100%

Vasectomy

$60 copay

[when performed in the physician office]

X-rays

Maximum Savings/Tier 1: 100% no deductible no copay
Standard Savings/Tier 2: 100% no deductible after $50 copay

Pharmacy (Retail)

$10 generic; $40 brand name; $100 non-formulary -- up to a 30-day supply.

Specialty medication classification will have a 10% co-insurance payment applied up to a $200 max cost per prescription.

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

Fertility drugs covered at 50% (deductible does not apply); max benefit of $10,000 per lifetime

Cost Saver provides eligible members with automatic access to GoodRx's prescription pricing that allows them to pay lower prices, when available, on generic medications. This experience is seamless. All members have to do is present their member ID card, when they pick up their prescriptions at their in-network pharmacy.

Mail order drug program

$20 generic; $100 brand name; $250 non-formulary -- up to a 90-day supply at CVS mail order or CVS retail pharmacies. Specialty drugs are not available via mail order.

Must use CVS mail-order service

Birth Control Pills

Included in Prescription Drug benefit

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 are covered.

Prostate Specific Antigen test - PSA

100%

Well-woman visits

100%

Vision care

Up to age 22 - 100%
Age 22 and over - $60

Limited to screen and refraction exams only

Transgender Services

Transgender Procedures subject to the applicable prior approval based upon the procedure, which may include, but limited to: clinical diagnosis, office/progress notes from provider(s), referral letter(s), and other applicable information:

Mastopexy/Breast Augmentation, Voice and communication therapy, including B60 for therapy performed by other professionals (i.e. voice coach, bodily movement coach); Trachael shave, Suction-assisted lipoplasty of the waist, Rhinoplasty, Facial bone reduction, Face lift, Blepharoplasty, Laryngoplasty/vocal cord (voice surgery), Liposuction (contour modeling of the waist), Lipofilling (breast, body, face), Gluteal augmentation, Permanent hair remova+B60l, Subcutaneous injection of filling material, Demabrasion, Chemical peel, Excision, excessive skin, and subcutaneous tissue; abdomen, inframubilical panniculectomy; Hair implants, Hair cranial prosthesis (wigs), Liposuction to reduce fat in hips, thighs, buttocks; Male chest reconstruction, Pectoral implants, Calf implants, Geniplasty and chin augmentation; Abdominoplasty, Facial bone reconstruction, Other electrolysis or hair laser removal, Laryngoplasty/vocal cord (voice surgery), Reversal treatment, in case a member decides to reverse procedures.

No Lifetime Limit.

Travel and Lodging

Contact the plan for details.