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Stanford HealthCare Alliance Plan - Group # 868025 - 2020

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 and Outpatient mental health office visits (see Mental Health section).

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

Employee Only: $40.00
Employee & Spouse/Registered Domestic Partner: $255.55
Employee & Children: $221.96
Employee & Family: $331.96

Part-Time Employee * Contribution Per Pay Period: 

Employee Only: $375.35
Employee & Spouse/Registered Domestic Partner: $860.15
Employee & Children: $737.27
Employee & Family: $1,187.81

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.
 

Referral Requirement
Visits to a specialist will now 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.

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.) 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.

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: 

10%  coinsurance **Pre authorization required

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: 

10% co-insurance.  **pre authorization required

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 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 presciption.

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

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