Stanford Health Care Alliance (SHCA) Plan - Group # 868025
Basics
Full-Time Employee * Contribution Per Pay Period
Employee Only $66.00
Employee & Spouse/Registered Domestic Partner $421.66
Employee & Child(ren) $366.23
Employee & Family $547.73
Employee & Spouse/Registered Domestic Partner $421.66
Employee & Child(ren) $366.23
Employee & Family $547.73
Part-Time Employee * Contribution Per Pay Period
Employee Only $506.14
Employee & Spouse/Registered Domestic Partner $1,145.35
Employee & Child(ren) $981.73
Employee & Family $1,581.68
Employee & Spouse/Registered Domestic Partner $1,145.35
Employee & Child(ren) $981.73
Employee & Family $1,581.68
Lifetime maximum
No maximum
Plan Year
2023
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.
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
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.
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.
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.
If the midwife is part of the Stanford Health Care Alliance network.
Prenatal Visits
100%
Doctor Delivery Charge
100%
Reproductive Health
$125 copay
If hospitalized, the $150 Hospital Stay copayment will also apply.
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).
If hospitalized, the $150 Hospital Stay copayment will also apply.
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).
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.
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.
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.
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
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.
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.
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.
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
Up to 20 visits per year
Network providers only
Allergy Tests
100%
Office co-pay may apply.
Office co-pay may apply.
Allergy Treatment
100%
Office co-pay may apply.
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
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
$75 co-pay
Hearing Care
Exam $75 co-pay
Hearing aids not covered
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% (with no deductible applied) of Stanford Health Care Alliance allowed charges for professional and diagnostic services; limited to three cycles of intrauterine insemination (IUI).
ART, Advanced Reproductive Technology, which includes In Vitro, GIFT, and ZIFT: Covered at 50% (with no deductible applied) for up to 3 cycles with cryopreservation available for each IVF cycle.
Egg, sperm and cryopreservation (embryo) freezing and thawing are covered per batch. There is a limit of 3 cryopreservation cycles. There is no limit on the number of retrievals. There is no FSH criteria required.
Fertility drugs: see Pharmacy
Fertility drugs are covered at 50% (deductible does not apply); max benefit of $10,000 per lifetime
*Artificial insemination and ovulation induction are covered regardless of partner status and without a diagnosis of infertility.
ART, Advanced Reproductive Technology, which includes In Vitro, GIFT, and ZIFT: Covered at 50% (with no deductible applied) for up to 3 cycles with cryopreservation available for each IVF cycle.
Egg, sperm and cryopreservation (embryo) freezing and thawing are covered per batch. There is a limit of 3 cryopreservation cycles. There is no limit on the number of retrievals. There is no FSH criteria required.
Fertility drugs: see Pharmacy
Fertility drugs are covered at 50% (deductible does not apply); max benefit of $10,000 per lifetime
*Artificial insemination and ovulation induction are covered regardless of partner status and without a diagnosis of infertility.
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
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
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
$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]
$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]
[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 copayment plus 25% of billed charges
Fertility drugs are covered at 50% (deductible does not apply); max benefit of $10,000 per lifetime
Non-Network pharmacy: Member pays copayment plus 25% of billed charges
Fertility drugs are covered at 50% (deductible does not apply); max benefit of $10,000 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
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]
[as part of the office visit]
Mammograms
100%
Immunizations
100%
Travel immunizations not covered.
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
Age 22 and over - $75
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.
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.
Travel and Lodging
Travel and Lodging for any covered service except National Medical Excellene, Institutes of Excellence/Institutes of Quality and Gene Therapy.
All options include the following parameters:
-Members must travel to a location where the services are legally permissible.
-Members will need to verify there is no in-network within 100 miles of their place of residence. For all services, except abortion, members are required to call Member Care Services to confirm provider availability.
-Per IRS regulation, the lodging reimbursement is limited to $50 per night per patient, up to $100 total per night including the patient's travel companion
-Plan year maximum for reimbursement is $10,000.
-Members are responsible for attesting there is no network provider within 100 miles of their home address.
All options include the following parameters:
-Members must travel to a location where the services are legally permissible.
-Members will need to verify there is no in-network within 100 miles of their place of residence. For all services, except abortion, members are required to call Member Care Services to confirm provider availability.
-Per IRS regulation, the lodging reimbursement is limited to $50 per night per patient, up to $100 total per night including the patient's travel companion
-Plan year maximum for reimbursement is $10,000.
-Members are responsible for attesting there is no network provider within 100 miles of their home address.