Stanford Health Care Alliance

Overview

The SHCA plan requires you to designate a primary care provider (PCP) to coordinate your care. While Aetna provides administrative support for the SHCA plan, members do not access the Aetna network. SHCA is a separate, regional network of providers and facilities in the Bay Area.

You may visit any SHCA network doctor or hospital. Check the SHCA website for a list of in-network providers. Some services require prior authorization from your PCP.

There is no benefit if you see a Non-Network provider, except for emergency care or when clinically appropriate and prior authorized by SHCA.

Group #868025

Referral Requirement

Visits to a specialist 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.

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 pre-certification requirement list.

Office copay

$30 copay primary/$75 copay specialist

Deductible

No deductible

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.)

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

Pharmacy (Retail)

SHCA uses the Aetna Network pharmacies:
$10 generic; $40 brand name; $100 non-formulary -- up to a 30-day supply

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

Must use Aetna mail-order service

Birth Control Pills

Included in Prescription Drug benefit