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.

Know where to go for care

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. 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

BASICS

Benefit

Overview

The Stanford Select Copay Health Plan requires you to designate a primary care physician (PCP) to coordinate your care. 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	Tier 1: 100% no deductible, no copay Tier 2: 100% no deductible after $50 copay
Imaging	Tier 1: 100% no deductible after $50 copay Tier 2: 100% no deductible after $500 copay
Physical Therapy	Tier 1: $30 copay Tier 2: 100% no deductible after $60 copay

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.

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

Stanford Select Copay Health Plan Summary of Benefits and Coverage (SBC)

An SBC is an overview of plan benefits, deductibles, copays, and coverage levels for a variety of commonly-used medical treatments and services.

Stanford Select Copay Health Plan Summary Plan Description (EOC)

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.