Stanford Select Copay Health Plan
The Stanford Select Copay Health Plan, administered by Aetna, has a nationwide network. Medical care must be received in-network, and most services are covered by a copay. Out-of-network care is only covered in emergencies.
Network
The Stanford Select Copay Health Plan uses the Aetna Select Network, which includes Stanford Health Care (SHC), Sutter Health, including the Palo Alto Medical Foundation (PAMF) network, and University of California San Francisco (UCSF) providers.
Preferred Providers
Certain services, such as lab work, imaging, and physical therapy, will have lower copays for preferred in-network providers or facilities (Maximum Savings/Tier 1) than for other in-network or out-of-network providers and facilities (Standard Savings/Tier 2).
View the Aetna Maximum Savings Guide
Aetna formulary for all three plans: Aetna Standard Plan
Outpatient Services
Aetna will help you locate high-quality and cost-effective options for diagnostic services, lab draws, imaging, colonoscopies, and other services. Visit Aetna’s website to compare costs or contact Aetna member services at 833-971-4583.
Advocacy Services and Clinical Care Management
Aetna offers a concierge program to help you maximize your benefits and guide you to the right resources. Clinical care specialists assist you in managing chronic medical conditions, answering questions, and finding the right doctors. Get started at Aetna’s website.
| BASICS | Benefit |
|---|---|
| Overview | The Stanford Select Copay Health Plan requires you to designate a primary care physician (PCP) to coordinate your care. If you do not select a PCP, a PCP will be auto assigned to you based upon your claims history and an available physician based upon your location. The Stanford Select Copay Health Plan uses the Aetna Select nationwide network. You must receive all non-emergency care from in-network providers. You may visit any SHCA network doctor or hospital. Some services require prior authorization from your PCP. There is no benefit if you see a non-network provider, except for emergency care. Group #232361 Plan ID #001 |
| Referral Requirement | No referral is required to see most specialists. There may be specific cases where a referral is required however (i.e. neurosurgeon). |
| 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 precertification requirement list. |
| Deductible | No deductible |
| Out-of-Pocket Maximum | $3,500 per individual/$7,000 familyA 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.) |
| PREVENTIVE CARE | Benefit |
|---|---|
| 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% |
| MEDICAL SERVICES | Benefit |
|---|---|
| Diagnostic Testing (X-ray, blood work) | Preferred in-network: no charge Other in-network: $50 copay Out-of-network: not covered |
| Imaging (CT/PET Scans, MRIs) | Preferred in-network: $50 copay Other in-network: $500 copay Out-of-network: not covered |
| Rehab – Physical Therapy | Preferred in-network: $30 copay Other in-network: $75 copay Out-of-network: not covered |
| Primary Care | In-network: $30 copay Out-of-network: not covered |
| Specialty Care | In-network: $60 copay Out-of-network: not covered |
| Urgent Care | In-network: $75 copay Out-of-network: not covered |
| Emergency Care | In-network: $200 copay (waived if admitted) Out-of-network: $200 copay (waived if admitted) |
| PRESCRIPTION DRUGS | Benefit |
| Pharmacy (Retail) | $10 generic; $40 brand name; $100 non-formulary — up to a 30-day supplyOut-of-network Pharmacy: not covered |
| Mail-Order Drug Program | $20 generic; $100 brand name; $250 non-formulary — up to a 90-day supplyMust use Aetna mail-order service |
| Birth Control Pills | Included in prescription drug benefit |
Tiered Services: Maximum Savings/Tier 1. Standard Savings/Tier 2.
| Labs |
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| Imaging |
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| Physical Therapy |
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Learn more about how you can reduce your costs when accessing these services on the Aetna Maximum Savings Guide.
| REPRODUCTIVE HEALTH | Benefit |
|---|---|
| Abortion services | The Stanford Select Copay Health Plan provides abortion services as they remain protected under California state law. As this is a network-only plan, members in states that ban or restrict access to abortion services may have to travel to a network location if one is not available within 100 miles of their ZIP code. Travel and lodging will be covered. The copay for pregnancy termination services is $125 and, if hospitalization is required, the $150 hospital copay would be applied as well. |
Traveling Outside the U.S.
Aetna provides “Emergency Care” coverage anywhere you may experience an emergency that is life-threatening in nature. Contact Aetna at 833-971-4583 or 800-872-3862 to locate an approved facility for non-emergency/non-life-threatening medical services.
- Learn more about traveling outside the U.S.
- If you need to file a claim for emergency care received while overseas, contact Aetna at 855-888-9046 or 215-775-6445 to have an international claim form sent to you.
Plan Information and Resources for the Stanford Select Copay Health Plan
2024 Plan Documents
An SBC is an overview of plan benefits, deductibles, copays, and coverage levels for a variety of commonly-used medical treatments and services.
An SPD or EOC is the official, detailed plan document for each plan outlining information about eligibility; costs and cost-sharing; included and excluded services; claims process; procedures for filing grievances, complaints and appeals.