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Stanford Health Care Alliance (SHCA) Plan - Group # 868025

Basics

Full-Time Employee * Contribution Per Pay Period

Employee Only: $52.80
Employee & Spouse/Partner: $337.33
Employee & Children: $292.99
Employee & Family: $438.19

Part-Time Employee * Contribution Per Pay Period

Employee Only: $429.93
Employee & Spouse/Partner: $978.82
Employee & Children: $838.99
Employee & Family: $1,351.71

Lifetime maximum

No maximum

Plan Year

2022

Pre-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.

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

Visits to specialists require a PCP referral, including any specialist you see for ongoing care or as a new patient. Without a PCP referral, visits may be denied due to lack of referral. Exception: Well-woman exams with an OB/GYN, outpatient professional mental health and substance abuse specialists, chiropractic care and acupuncture do not require a referral.

Offered To

Active Employees

Care Management

Participation in care management required for certain conditions and diseases.

Body/Description

The Stanford Health Care Alliance ACO plan requires you designate a primary care provider to coordinate all of your care.  You may visit any Stanford Health Care 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 Health Care Alliance and Outpatient mental health office visits (see Mental Health section).

Coinsurance

100% after applicable co-pays

Office co-pay

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

100%

Maternity Hospital Stay

$150 co-pay per admission

Baby's First Exam

100%

Birthing Centers

$150 co-pay per admission


If the birthing center is part of the Stanford Health Care Alliance network.

Midwives

100%

If the midwife is part of the Stanford Health Care 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

Pre-certification may be required by you or your provider.

INPATIENT CARE ** pre-authorization required
$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 may be required by you or your provider.

INPATIENT CARE ** pre-authorization required
$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.

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

CT Scans

Covered at 90% with no deductible; **Pre-authorization required. 10% member coinsurance.

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.

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

Covered at 90% with no deductible; **Pre-authorization required. 10% member coinsurance.

Durable Medical Equipment

100% **pre authorization requirement

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

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%

Pharmacy (Retail)

Stanford Health Care Alliance uses the Aetna Network pharmacy: $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 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; Specialty drugs are not available via mail order.

Must use Aetna 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 not covered.

Prostate Specific Antigen test - PSA

100%

Well-woman visits

100%

Vision care

Up to age 22 - 100%
Age 22 and over - $75

Limited to screen and refraction exams only