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
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
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.
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.
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.
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
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
If the birthing center is part of the Aetna network
Midwives
100%
If the midwife is part of the Aetna network
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.
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.
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.
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
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 (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
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
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
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."
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
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
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.
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.
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
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
$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]
[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
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.
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
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]
[as part of the office visit]
Mammograms
100%
Immunizations
100%
Travel immunizations are covered.
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
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.
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.