Aetna Student Health
Plan Design and Benefits
Summary
Open Access Elect Choice
EPO
Stanford University
Policy Year: 2023–2024
Policy Number: 198839
https://www.aetnastudenthealth.com
(888) 834-4708
Disclaimer: These rates and benefits are pending approval by the California Department of
Insurance and can change. If they change, we will update this information.
Stanford University 2023-2024 Page 2
This is a brief description of the Student Health Plan. The plan is available for the Stanford University students. The plan
is insured by Aetna Life Insurance Company (Aetna). The exact provisions, including definitions, governing this insurance
are contained in the Certificate available to you and may be viewed online at https://www.aetnastudenthealth.com. If
there is a difference between this Plan Summary and the Certificate, the Certificate will control.
Vaden Health Center
Vaden Health Center is a multidisciplinary outpatient clinic serving registered Stanford students. The staff of over 100
professionals offers primary care medical services, psychiatric and counseling services, confidential support for those
impacted by sexual/relationship abuse, wellness promotion, and health insurance and referral services. Additional
clinical services include radiography, laboratory, injection and immunization, travel medicine, nutrition counseling,
pharmacy, physical therapy, and some specialty care.
For Vaden Health Center’s hours of operation see the website at vaden.stanford.edu.
Who is eligible for Cardinal Care and Dependent Care?
Students, while attending Stanford University, must be covered by health insurance that meets specific
parameters. Cardinal Care, the student health insurance plan, is one such option. Students are automatically enrolled in
Cardinal Care at the start of their entry quarter each year and have until the waiver deadline of their entry quarter to
choose to remain enrolled or waive. Students entering Stanford for the first time who need health insurance coverage
for dependents can enroll them only during a defined period of open enrollment that coincides with their student’s
initial matriculation unless a qualifying life event occurs at a later date.
Student Coverage Dates and Rates
Coverage for all enrolled students will become effective at 12:01 AM on the Coverage Start Date indicated below and
will terminate at 11:59 PM on the Coverage End Date indicated.
The rates below include premiums for the Plan underwritten by Aetna Life Insurance Company (Aetna).
Annual
09/01/2023-
08/31/2024
Waiver Deadline:
09/15/2023
Winter
01/01/2024-
08/31/2024
Waiver Deadline:
12/15/2023
Spring
04/01/2024-
08/31/2024
Waiver Deadline:
03/15/2024
Summer
06/01/2024-
08/31/2024
Waiver Deadline:
06/15/2024
Student
$7,128
$4,752
$2,970
$1,782
Dependent Care Eligibility
Students enrolled in Cardinal Care can enroll their spouse, registered domestic partner, and dependent children up to
the age of 26. Students can enroll a dependent in Dependent Care only during a defined period of open enrollment that
coincides with their student’s first 30 days of matriculation unless a qualifying life event occurs at a later date. A
qualifying life event will open a 31-day enrollment period.
Dependent Care Dates and Rates
Coverage for enrolled dependents will become effective at 12:00 AM on the Coverage Start Date indicated below and
will terminate at 11:59 PM on the Coverage End Date indicated. Coverage for insured dependents terminates in
accordance with the Termination Provisions described in the Certificate.
Stanford University 2023-2024 Page 3
The rates below include premiums for Dependent Care underwritten by Aetna Life Insurance Company (Aetna).
Autumn
09/01/2023-
08/31/2024
Enrollment Deadline:
09/30/2023
Winter
01/01/2024-
08/31/2024
Enrollment Deadline:
1/30/2024
Spring
04/01/2024-
08/31/2024
Enrollment Deadline:
04/30/2024
Summer
06/01/2024-
08/31/2024
Enrollment Deadline:
06/30/2024
Monthly Rate
Spouse
$578.00
Child
$300.56
Two or More Children
$541.02
Spouse + Child
$878.56
Spouse + Children
$1119.02
Certificate
Your certificate describes the benefits covered by your Aetna plan. The schedule of benefits in your certificate tells you
how we share expenses for eligible health services and tells you about limits and gives you a summary of how your plan
works.
Request to Waive
Students are automatically enrolled in Cardinal Care, at the start of their entry quarter each year. The plan year begins
on September 1
st
and ends on August 31
st
. If you opt to use alternative health insurance coverage, you must
formally request to waive Cardinal Care by the end of the applicable deadline below, or you will remain enrolled
from your quarter of entry until the end of the plan year (August 31) and will be responsible for paying the
corresponding costs which can be significant.
Review your policy carefully before deciding to request a waiver from Cardinal Care
coverage. If you are approved for
a waiver, you will not
be eligible for Cardinal Care
for the remainder of the plan year unless
you have a pre-defined
qualifying life event.
Students who initially opt to waive Cardinal Care, who then lose health insurance coverage or age out of a parent’s
health insurance plan at age 26, and who wish to have coverage through Cardinal Care, have
31 days
to apply at
stanford.mycare26.com/cardinalcare. In most instances, coverage will commence at the start of the next month.
Similarly, students whose dependents lose health insurance coverage and who wish to enroll their dependent(s) in
the Stanford Dependent Health Insurance Plan, Dependent Care, have
31 days
to apply at
stanford.mycare26.com/cardinalcare.
Note that students must be enrolled in Cardinal Care
to enroll dependents in
the Stanford Dependent Care Plan.
Stanford University 2023-2024 Page 4
YOU MUST MAKE YOUR HEALTH INSURANCE DECISION EVERY YEAR
If you choose not to have health insurance coverage through Cardinal Care, you will need to
waive EACH academic year by the applicable
deadline. A decision made in one plan
year does not
carry over to the next.
Quarter entering Stanford
Deadline to Convey Your Health Insurance Decision
(Stay Enrolled in Cardinal Care or Waive Coverage)
Autumn Quarter
September 15
Winter Quarter
December 15
Spring Quarter
March 15
Summer Quarter
June 15
Your Alternative Health Care Plan Must Have Comparable Benefits
In order to be approved for a waiver from Cardinal Care coverage, you must have health insurance coverage that
meets or exceeds Stanford’s minimum standards. These requirements ensure that your health care needs will be
adequately covered while you are at Stanford.
Your alternative health insurance policy must meet
or exceed the following minimum standards:
• Covers the entire academic year (September 1 through August 31). Gaps in coverage are not allowed.
•
Covers inpatient and outpatient medical care in the San Francisco Bay Area (with
strong preference for
access to providers
at Stanford University Medical Center and/or the Sutter Health Providers).
•
Coverage for inpatient and outpatient mental health care in the San Francisco Bay Area (with
strong
preference for access to providers
at Stanford University Medical Center and/or the Sutter Health
Providers).
• Has an annual deductible $1,000 USD or less (some employer plans may be exempted from this requirement).
• Has an annual out of pocket maximum of $9,100 USD or less (some employer plans may be exempted from this
requirement).
• Provides the Essential Minimum Benefits require by the Patient Protection and Affordable Care Act (PPACA)
with no annual or lifetime maximums.
• Covers 100% of Preventative Care as defined by the PPACA.
• Contains no exclusions for pre-existing conditions.
• Offers prescription drug coverage.
•
Offers coverage for non-emergency as well as emergency care.
• Has lifetime aggregate maximum benefit of at least $2,000,000 USD OR a maximum per condition/per lifetime
benefit of $500,000 USD.
Dependent Care Enrollment
To enroll the dependent(s) of a Cardinal Care student, please log on to stanford.mycare26.com/cardinalcare. Dependent
Care online application will not be accepted after the enrollment period deadline, unless there is a qualifying life event
that directly affects their insurance coverage. (Examples of a qualifying life event would be loss of health coverage under
another health plan, marriage, birth of a child.)
Stanford University 2023-2024 Page 5
Important note regarding coverage for a newborn infant or newly adopted child:
• A newborn child - Your newborn child is covered on your Cardinal Care health insurance plan for the first 31 days
from the moment of birth.
- You must still enroll the child within 31 days of birth even when coverage does not require payment of
an additional premium contribution for the newborn.
- If you miss this deadline, your newborn will not have health benefits after the first 31 days.
- If your coverage ends during this 31 day period, then your newborn coverage will end on the same date
as your coverage. This applies even if the 31 day period has not ended.
• An adopted child or a child legally placed with you for adoption - A child that you, or that you and your spouse,
civil union partner or domestic partner adopts or is placed with you for adoption, is covered on your plan for the
first 31 days after the adoption or the placement is complete.
- You must still enroll the child within 31 days of the adoption or placement for adoption even when
coverage does not require payment of an additional premium contribution for the child.
- If you miss this deadline, your adopted child or child placed with you for adoption will not have health
benefits after the first 31 days.
- If your coverage ends during this 31 day period, then coverage for your adopted child or child placed
with you for adoption will end on the same date as your coverage. This applies even if the 31 day period
has not ended.
If you need information or have questions on dependent enrollment, call our enrollment partner Academic Health Plans
at 855-343-8387
Cardinal Care and Leaves of Absence
If you are covered by Cardinal Care and contemplate taking a leave of absence at any point in your academic career,
be sure to contact Vaden Health Center’s Insurance and
Referral Office for guidance about coverage,
in advance, if
possible. As you’ll see below,
timing can be a driver as to whether coverage
will be preserved.
A student who is granted a Leave of Absence in Autumn Quarter for which the effective date of the leave is prior to the
first day of class will not be charged tuition or any associated fees for the quarter. Upon reversal of the tuition, the
student’s eligibility for enrollment in Cardinal Care will be canceled retroactive to September 1. (The student’s eligibility for
enrollment in Cardinal Care will resume upon return to the university and reinstatement of tuition.)
A student who is granted a Leave of Absence in
Autumn Quarter for which the effective date of the leave is on or after the
first day of class
but before the term withdrawal deadline will
be charged (prorated) tuition and associated fees for the
quarter after confirmation of attendance in classes or participation in units by the Office of the University Registrar. If
enrolled in Cardinal Care, the student will remain enrolled through the end of the plan
year (August 31) and applicable
fees will apply.
A student who is enrolled in Cardinal Care as of Autumn Quarter, and who is granted a Leave of Absence for a subsequent
quarter (i.e., Winter Quarter, Spring Quarter, or Summer Quarter) will remain enrolled in and covered by Cardinal Care
through the end of the plan year (August 31) and applicable fees will apply.
A student who returns to the university in Winter Quarter or Spring Quarter, and who is subsequently granted a
Leave of Absence, i.e., if the effective date of the leave is prior to the first day of class, tuition and any associate
fees for the quarter will be reversed. Upon reversal of the tuition, the student’s eligibility for enrollment in Cardinal
Care will be cancelled retroactively to the start of the applicable coverage period (January 1 for Winter Quarter
entry student and April 1 for Spring Quarter entry students) the effective date of the leave is on or after the first
day of class but before the respective term withdrawal deadline, the student will be charged (prorated) tuition and
associated fees for the quarter after confirmation of attendance in classes, or participation in units, by the Office
of the University Registrar. If enrolled in Cardinal Care, the student will remain enrolled through the end of the plan
year (August 31) and applicable fees will apply.
Stanford University 2023-2024 Page 6
Service area
Your plan generally pays for eligible health services only within a specific geographic area, called a service area. There
are some exceptions, such as for Tier 2, emergency services, urgent care and transplants.
Medicare Eligibility Notice
You are not eligible to enroll in the student health plan if you have Medicare at the time of enrollment in this student
plan. The plan does not provide coverage for people who have Medicare.
Precertification (Prior Authorization)
You do not need to obtain precertification for any services. However, your provider is required to obtain precertification
for certain Preferred Care services. Refer to the Precertification provisions in the Coverage section of the Certificate for a
complete description of the precertification programs including the types of services, treatments, procedures, visits or
supplies that require precertification. No penalty will be applied to you for a Preferred Care service that was not pre-
certified.
Coordination of Benefits (COB)
Some people have health coverage under more than one health plan. If you do, we will work together with your other
plan(s) to decide how much each plan pays. This is called coordination of benefits (COB). A complete description of the
Coordination of Benefits provision is contained in the Certificate available to you.
Stanford University 2023-2024 Page 7
Plan Design and Benefits Summary
The Plan excludes coverage for certain services and has limitations on the amounts it will pay. While this Plan Summary
document will tell you about some of the important features of the Plan, other features that may be important to you
are defined in the Certificate. To look at the full Plan description, which is contained in the Certificate available to you,
go to https://www.aetnastudenthealth.com.
This Plan will pay benefits in accordance with any applicable California Insurance Law(s).
Tier 1 (Stanford Health
Care, Menlo Medical
Clinic, Sutter Health) In-
network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Policy year deductibles
You have to meet your policy year deductible before this plan pays for benefits.
Student
$100 per policy year
$500 per policy year
Not Applicable
Spouse
$100 per policy year
$500 per policy year
Not Applicable
Each child
$100 per policy year
$500 per policy year
Not Applicable
Family
$300 per policy year
$1,500 per policy year
Not Applicable
Policy year deductible waiver
The policy year deductible is waived for all of the following eligible health services:
•
Tier 2 in-network care for Preventive care and wellness,
•
Tier 2 in-network care for Pediatric Dental Care type A services,
•
Tier 2 in-network care for Pediatric Vision Care Services and Supplies,
•
Tier 2 in-network care for Physicians, Specialists and consults office visits,
•
Tier 2 in-network care for first postnatal visit,
•
Tier 2 in-network care for Well Newborn Nursery Care,
•
Tier 2 in-network care for Walk-in clinic visits,
•
Tier 2 in-network care for Hospital emergency room,
•
Tier 2 in-network care for Urgent care,
•
Tier 2 in-network care outpatient mental health and substance abuse office visits,
•
Tier 2 in-network care Ambulance services,
•
Tier 2 in-network care for hearing aid exams,
•
Tier 2 in-network care for routine adult vision exams,
•
Tier 2 in-network care for Outpatient Prescription Drugs.
The Tier 1 in-network care policy year deductible applies to the following eligible health services:
•
Inpatient hospital (room and board)
•
Outpatient surgery (facility charges)
•
Treatment of infertility
Individual
This is the amount you owe for select care and in-network eligible health services each policy year before the plan
begins to pay for eligible health services. After the amount you pay for eligible health services reaches the policy year
deductible, this plan will begin to pay for eligible health services for the rest of the policy year.
Stanford University 2023-2024 Page 8
Tier 1 (Stanford Health
Care, Menlo Medical
Clinic, Sutter Health) In-
network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Maximum out-of-pocket limits
Student
$2,000 per policy year
$4,000 per policy year
Not Applicable
Spouse
$2,000 per policy year
$4,000 per policy year
Not Applicable
Each child
$2,000 per policy year
$4,000 per policy year
Not Applicable
Family
$6,000 per policy year
$12,000 per policy year
Not Applicable
Eligible health services
Tier 1 (Stanford Health Care,
Menlo Medical Clinic, Sutter
Health) In-network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Routine physical exams
Performed at a physician’s office
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
Not covered
Maximum age and visit limits per
policy year through age 21
Subject to any age and visit limits provided for in the
comprehensive guidelines supported by the American
Academy of Pediatrics/Bright Futures//Health Resources and
Services Administration guidelines for children and
adolescents.
Not Applicable
Covered persons age 22 and
over: Maximum visits per policy
year
1 visit
Not Applicable
Preventive care immunizations
Performed in a facility or at a
physician's office
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
Not covered
Maximums
Subject to any age limits provided for in the comprehensive
guidelines supported by Advisory Committee on
Immunization Practices of the Centers for Disease Control and
Prevention
Not Applicable
Routine gynecological exams (including Pap smears and cytology tests)
Performed at a physician’s,
obstetrician (OB), gynecologist
(GYN) or OB/GYN office
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
Not covered
Maximum visits per policy year
1 visit
Not Applicable
Stanford University 2023-2024 Page 9
Eligible health services
Tier 1 (Stanford Health Care,
Menlo Medical Clinic, Sutter
Health) In-network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Preventive screening and counseling services
Preventive screening and
counseling services for Obesity
and/or healthy diet counseling,
Misuse of alcohol & drugs,
Tobacco Products, Depression
Screening, Sexually transmitted
infection counseling & Genetic
risk counseling for breast and
ovarian cancer
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
Not covered
Stress management counseling
office visits
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
Not covered
Chronic condition counseling
office visits
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
Not covered
Routine cancer screenings
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
Not covered
Maximum:
Subject to any age; family history; and frequency guidelines
as set forth in the most current:
•
Evidence-based items that have in effect a rating of A or B
in the current recommendations of the United States
Preventive Services Task Force; and
•
The comprehensive guidelines supported by the Health
Resources and Services Administration.
Not Applicable
Lung cancer screening maximums
1 screening every 12 months*
Not Applicable
Prenatal and postpartum care
services -Preventive care services
only (includes participation in the
California Prenatal Screening
Program)
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
Not covered
Lactation support and counseling
services
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
Not covered
Stanford University 2023-2024 Page 10
Eligible health services
Tier 1 (Stanford Health Care,
Menlo Medical Clinic, Sutter
Health) In-network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Breast pump supplies and
accessories
100% (of the negotiated
charge) per item
No copayment or policy year
deductible applies
100% (of the negotiated
charge) per item
No copayment or policy year
deductible applies
Not covered
Family planning services – female contraceptives
Female contraceptive counseling
services
office visit
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
100% (of the negotiated
charge) per visit
No copayment or policy year
deductible applies
Not covered
Female contraceptive
prescription drugs and devices
provided, administered, or
removed, by a provider during an
office visit
For each 30 day supply or 12
month supply
100% (of the negotiated
charge) per item
No copayment or policy year
deductible applies
100% (of the negotiated
charge) per item
No copayment or policy year
deductible applies
Not covered
Female Voluntary sterilization-
Inpatient & Outpatient provider
services
100% (of the negotiated
charge)
No copayment or policy year
deductible applies
100% (of the negotiated
charge)
No copayment or policy year
deductible applies
Not covered
The following are not covered under this benefit:
•
Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA
Physicians and other health professionals
Physician, specialist including
Consultants Office visits (non-
surgical/non-preventive care by a
physician and specialist) includes
telemedicine consultations)
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit
No policy year deductible
applies
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit
No policy year deductible
applies
Not covered
Allergy testing and treatment
Allergy testing performed at a
physician or specialist office
100% (of the negotiated
charge)
No policy year deductible
applies
70% (of the negotiated
charge)
Not covered
Stanford University 2023-2024 Page 11
Eligible health services
Tier 1 (Stanford Health
Care, Menlo Medical Clinic,
Sutter Health) In-network
coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Allergy injections treatment
performed at a physician’s, or
specialist office [when you see
the physician]
100% (of the negotiated
charge)
No policy year deductible
applies
70% (of the negotiated
charge)
Not covered
Allergy sera and extracts
administered via injection at a
physician’s or specialist’s office
100% (of the negotiated
charge)
No policy year deductible
applies
70% (of the negotiated
charge)
Not covered
Physician and specialist surgical services
Inpatient surgery performed
during your stay in a hospital or
birthing center by a surgeon
(includes anesthetist and surgical
assistant expenses)
100% (of the negotiated
charge)
No policy year deductible
applies
70% (of the negotiated
charge)
Not covered
The following are not covered under this benefit:
•
The services of any other physician who helps the operating physician
•
A stay in a hospital (Hospital stays are covered in the Eligible health services and exclusions – Hospital and other facility
care section)
•
Services of another physician for the administration of a local anesthetic
Outpatient surgery performed at
a physician’s or specialist’s office
or outpatient department of a
hospital or surgery center by a
surgeon (includes anesthetist and
surgical assistant expenses)
100% (of the negotiated
charge) per visit
No policy year deductible
applies
70% (of the negotiated
charge) per visit
Not covered
The following are not covered under this benefit:
•
The services of any other physician who helps the operating physician
•
A stay in a hospital (Hospital stays are covered in the Eligible health services and exclusions – Hospital and other facility
care section)
•
A separate facility charge for surgery performed in a physician’s office
•
Services of another physician for the administration of a local anesthetic
Alternatives to physician office visits
Walk-in clinic visits
(non-emergency visit)
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit thereafter
No policy year deductible
applies
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit thereafter
No policy year deductible
applies
Not covered
Stanford University 2023-2024 Page 12
Eligible health services
Tier 1 (Stanford Health
Care, Menlo Medical Clinic,
Sutter Health) In-network
coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Hospital and other facility care
Inpatient hospital (room and
board) and other
miscellaneous services and
supplies)
Includes birthing center facility
charges
$500 copayment then the
plan pays 100% (of the
balance of the negotiated
charge) per admission
70% (of the negotiated
charge) per admission
Not covered
Preadmission testing
Covered according to the type of benefit and the place
where the service is received.
Not covered
In-hospital non-surgical physician
services
100% (of the negotiated
charge) per visit
No policy year deductible
applies
70% (of the negotiated
charge) per visit
Not covered
Alternatives to hospital stays
Outpatient surgery (facility
charges) performed in the
outpatient department of a
hospital or surgery center
$250 copayment then the
plan pays 100% (of the
balance of the negotiated
charge)
70% (of the negotiated
charge)
Not covered
The following are not covered under this benefit:
•
The services of any other physician who helps the operating physician
•
A stay in a hospital (See the Hospital care – facility charges benefit in this section)
•
A separate facility charge for surgery performed in a physician’s office
•
Services of another physician for the administration of a local anesthetic
Home health Care
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit thereafter
No policy year deductible
applies
70% (of the negotiated
charge) per visit
Not covered
Maximum visits per policy year
100
Not applicable
The following are not covered under this benefit:
•
Nursing and home health aide services or therapeutic support services provided outside of the home (such as in
conjunction with school, vacation, work or recreational activities)
•
Transportation
•
Services or supplies provided to a minor or dependent adult when a family member or caregiver is not present
•
Homemaker or housekeeper services
•
Food or home delivered services
•
Maintenance therapy
Stanford University 2023-2024 Page 13
Eligible health services
Tier 1 (Stanford Health
Care, Menlo Medical Clinic,
Sutter Health) In-network
coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Hospice-Inpatient
100% (of the negotiated
charge) per admission
No policy year deductible
applies
70% (of the negotiated
charge) per admission
Not covered
Hospice-Outpatient
100% (of the negotiated
charge) per visit
No policy year deductible
applies
70% (of the negotiated
charge) per visit
Not covered
The following are not covered under this benefit:
•
Funeral arrangements
•
Financial or legal counseling which includes estate planning and the drafting of a will
•
Homemaker or caretaker services that are services which are not solely related to your care and may include:
-
Sitter or companion services for either you or other family members
-
Transportation
-
Maintenance of the house
Skilled nursing facility-
Inpatient
$500 copayment then the
plan pays 100% (of the
balance of the negotiated
charge)
70% (of the negotiated
charge)
Not covered
Maximum days of
confinement per policy year
unlimited
Not covered
Hospital emergency room
$100 copayment then the
plan pays 100% (of the
balance of the negotiated
charge) per visit
No policy year deductible
applies
$100 copayment then the
plan pays 100% (of the
balance of the negotiated
charge) per visit
No policy year deductible
applies
Paid the same as Tier 1 in-
network coverage
Non-emergency care in a hospital
emergency room
Not covered
Not covered
Not covered
Important note:
•
As out-of-network providers do not have a contract with us the provider may not accept payment of your cost share,
(copayment/coinsurance), as payment in full. You may receive a bill for the difference between the amount billed by the
provider and the amount paid by this plan. If the provider bills you for an amount above your cost share, you are not
responsible for paying that amount. You should send the bill to the address listed on the back of your ID card, and we will
resolve any payment dispute with the provider over that amount. Make sure the ID card number is on the bill.
•
A separate hospital emergency room copayment/coinsurance will apply for each visit to an emergency room. If you are
admitted to a hospital as an inpatient right after a visit to an emergency room, your emergency room
copayment/coinsurance will be waived and your inpatient copayment/coinsurance will apply.
•
Covered benefits that are applied to the hospital emergency room copayment/coinsurance cannot be applied to any other
copayment/coinsurance under the plan. Likewise, a copayment/coinsurance that applies to other covered benefits under
the plan cannot be applied to the hospital emergency room copayment/coinsurance.
Stanford University 2023-2024 Page 14
•
Separate copayment/coinsurance amounts may apply for certain services given to you in the hospital emergency room
that are not part of the hospital emergency room benefit. These copayment/coinsurance amounts may be different from
the hospital emergency room copayment/coinsurance. They are based on the specific service given to you.
•
Services given to you in the hospital emergency room that are not part of the hospital emergency room benefit may be
subject to copayment/coinsurance amounts that are different from the hospital emergency room copayment/coinsurance
amounts.
The following are not covered under this benefit:
•
Non-emergency services in a hospital emergency room facility, freestanding emergency medical care facility or
comparable emergency facility
Eligible health services
Tier 1 (Stanford Health Care,
Menlo Medical Clinic, Sutter
Health) In-network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Urgent care
$50 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit thereafter
No policy year deductible
applies
$50 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit thereafter
No policy year deductible
applies
$50 copayment then the plan
pays 100% (of the balance of
the recognized charge) per
visit thereafter
No policy year deductible
applies
Non-urgent use of an urgent care
provider
Not covered
Not covered
Not covered
The following is not covered under this benefit:
•
Non-urgent care in an urgent care facility (at a non-hospital freestanding facility)
Pediatric dental care (Limited to covered persons through the end of the month in which the person turns age 19.
Type A services
Tier 1 providers do not
provide dental services
100% (of the negotiated
charge) per visit
No copayment or deductible
applies
Not covered
Type B services
Tier 1 providers do not
provide dental services
80% (of the negotiated
charge) per visit
No copayment or deductible
applies
Not covered
Type C services
Tier 1 providers do not
provide dental services
50% (of the negotiated
charge) per visit
No copayment or deductible
applies
Not covered
Orthodontic services
Tier 1 providers do not
provide dental services
50% (of the negotiated
charge) per visit
No copayment or deductible
applies
Not covered
Dental emergency services
Tier 1 providers do not
provide dental services
Covered according to the
type of benefit and the place
where the service is received.
Not covered
Stanford University 2023-2024 Page 15
Pediatric dental care exclusion
The following are not covered under this benefit:
•
Asynchronous dental treatment
•
Cosmetic services and supplies including plastic surgery, reconstructive surgery, cosmetic surgery, personalization or
characterization of dentures or other services and supplies which improve alter or enhance appearance, augmentation
and vestibuloplasty, and other substances to protect, clean, whiten bleach or alter the appearance of teeth; whether or
not for psychological or emotional reasons. Facings on molar crowns and pontics will always be considered cosmetic.
•
Crown, inlays, onlays, and veneers unless:
-
It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material or
-
The tooth is an abutment to a covered partial denture or fixed bridge
•
Dental implants (that are determined not to be medically necessary mouth guards, and other devices to protect, replace
or reposition teeth
•
Dentures, crowns, inlays, onlays, bridges, or other appliances or services used:
-
For splinting
-
To alter vertical dimension
-
To restore occlusion
-
For correcting attrition, abrasion, abfraction or erosion
•
Treatment of any jaw joint disorder and treatments to alter bite or the alignment or operation of the jaw, including
temporomandibular joint dysfunction disorder (TMJ) and craniomandibular joint dysfunction disorder (CMJ) treatment,
orthognathic surgery, and treatment of malocclusion or devices to alter bite or alignment, except as covered in the
Eligible health services and exclusions – Specific conditions section
•
General anesthesia and intravenous sedation, unless specifically covered and only when done in connection with another
eligible health service
•
Mail order and at-home kits for orthodontic treatment
•
Orthodontic treatment except as covered in this section
•
Pontics, crowns, cast or processed restorations made with high noble metals (gold)
•
Prescribed drugs
•
Replacement of teeth beyond the normal complement of 32
•
Services and supplies:
-
Done where there is no evidence of pathology, dysfunction, or disease other than covered preventive services
-
Provided for your personal comfort or convenience or the convenience of another person, including a provider
-
Provided in connection with treatment or care that is not covered under your policy
•
Surgical removal of impacted wisdom teeth only for orthodontic reasons, except as medically necessary
•
Treatment by other than a dental provider
Eligible health services
Tier 1 (Stanford Health Care,
Menlo Medical Clinic, Sutter
Health) In-network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Diabetic services and supplies
(including equipment and
training)
Covered according to the
type of benefit and the place
where the service is received.
Covered according to the
type of benefit and the place
where the service is received.
Not covered
Podiatric (foot care) treatment
Physician and specialist non-
routine foot care treatment
Covered according to the
type of benefit and the place
where the service is received.
Covered according to the
type of benefit and the place
where the service is
received.
Not covered
The following are not covered under this benefit:
•
Services and supplies for:
-
The treatment of calluses, bunions, toenails, flat feet, hammertoes, fallen arches
-
The treatment of weak feet, chronic foot pain or conditions caused by routine activities, such as walking, running,
Stanford University 2023-2024 Page 16
working or wearing shoes
-
Supplies (including orthopedic shoes), foot orthotics, arch supports, shoe inserts, ankle braces, guards, protectors,
creams, ointments and other equipment, devices and supplies
-
Routine pedicure services, such as cutting of nails, corns and calluses when there is no illness or injury of the feet
Eligible health services
Tier 1 (Stanford Health
Care, Menlo Medical Clinic,
Sutter Health) In-network
coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Accidental injury to sound
natural teeth
100% (of the negotiated
charge)
No policy year deductible
applies
70% (of the negotiated
charge)
Not covered
The following are not covered under this benefit:
•
The care, filling, removal or replacement of teeth and treatment of diseases of the teeth
•
Dental services related to the gums
•
Apicoectomy (dental root resection)
•
Orthodontics
•
Root canal treatment
•
Soft tissue impactions
•
Bony impacted teeth
•
Alveolectomy
•
Augmentation and vestibuloplasty treatment of periodontal disease
•
False teeth
•
Prosthetic restoration of dental implants
•
Dental implants
Temporomandibular joint
dysfunction (TMJ) and
craniomandibular joint
dysfunction (CMJ) treatment
Covered according to the
type of benefit and the place
where the service is received.
Covered according to the
type of benefit and the place
where the service is received.
Not covered
The following are not covered under this benefit:
•
Dental implants
Blood and body fluid exposure
Covered according to the
type of benefit and the place
where the service is
received.
Covered according to the
type of benefit and the place
where the service is
received.
Not covered
The following are not covered under this benefit:
•
Services and supplies provided for the treatment of an illness that results from your clinical related injury as these are
covered elsewhere in the student policy
Clinical trial (routine patient
costs)
Covered according to the
type of benefit and the place
where the service is
received.
Covered according to the
type of benefit and the place
where the service is
received.
Not covered
The following are not covered under this benefit:
•
Services and supplies related to data collection and record-keeping that is solely needed due to the clinical trial (i.e.
protocol-induced costs)
•
Services and supplies provided by the trial sponsor without charge to you
•
The experimental intervention itself (except medically necessary Category B investigational devices and promising
Stanford University 2023-2024 Page 17
experimental and investigational interventions for terminal illnesses in certain clinical trials in accordance with Aetna’s
claim policies)
Eligible health services
Tier 1 (Stanford Health Care,
Menlo Medical Clinic, Sutter
Health) In-network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Dermatological treatment
Covered according to the
type of benefit and the place
where the service is received.
Covered according to the
type of benefit and the place
where the service is received.
Not covered
The following are not covered under this benefit:
•
Cosmetic treatment and procedures
Obesity bariatric Surgery and
services
Covered according to the
type of benefit and the place
where the service is
received.
Covered according to the
type of benefit and the place
where the service is
received.
Not covered
Obesity surgery-travel and lodging
Maximum benefit payable for
travel expenses for each round
trip – three round trips covered
(one pre-surgical visit, the
surgery and one follow-up visit)
$130
Not applicable
Maximum benefit payable for
travel expenses per companion
for each round trip – two round
trips covered (the surgery and
one follow-up visit)
$130
Not applicable
Maximum benefit payable for
lodging expenses per patient and
companion for the pre-surgical
and follow-up visits
$100 per day, up to two days
Not applicable
Maximum benefit payable for
lodging expenses per companion
for surgery stay
$100 per day, up to four days
Not applicable
The following are not covered under this benefit:
•
Weight management treatment or drugs intended to decrease or increase body weight, control weight or treat obesity,
including morbid obesity except as described above and in the Eligible health services and exclusions – Preventive care and
wellness section, including preventive services for obesity screening and weight management interventions. This is
regardless of the existence of other medical conditions. Examples of these are:
-
Drugs, stimulants, preparations, foods or diet supplements, dietary regimens and supplements, food supplements,
appetite suppressants and other medications
-
Hypnosis or other forms of therapy
-
Exercise programs, exercise equipment, membership to health or fitness clubs, recreational therapy or other forms of
activity or activity enhancement
Stanford University 2023-2024 Page 18
Eligible health services
Tier 1 (Stanford Health Care,
Menlo Medical Clinic, Sutter
Health) In-network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Maternity care that is not
considered preventive care
(includes delivery and postpartum
care services in a hospital or
birthing center)
Covered according to the
type of benefit and the place
where the service is received.
Covered according to the
type of benefit and the place
where the service is received.
Not covered
The following are not covered under this benefit:
•
Any services and supplies related to births that take place in the home or in any other place not licensed to perform
deliveries
Well newborn nursery
care in a hospital or
birthing center
100% (of the negotiated
charge) per visit
No policy year deductible
applies
70% (of the negotiated
charge) per visit
No policy year deductible
applies
Not covered
Family planning services – other
Voluntary sterilization
for males-inpatient surgical
services
$50 copayment then the plan
pays 100% (of the negotiated
charge)
No policy year deductible
applies
$100 copayment then the plan
pays 100% (of the negotiated
charge)
Not covered
Voluntary sterilization
for males-outpatient surgical
services
$50 copayment then the plan
pays 100% (of the negotiated
charge)
No policy year deductible
applies
$100 copayment then the plan
pays 100% (of the negotiated
charge)
Not covered
Abortion
Inpatient physician or specialist
surgical services
100% (of the negotiated
charge)
No policy year deductible
applies
100% (of the negotiated
charge)
No policy year deductible
applies
Not covered
Outpatient physician or
specialist surgical services
100% (of the negotiated
charge)
No policy year deductible
applies
100% (of the negotiated
charge)
No policy year deductible
applies
Not covered
Reversal of voluntary sterilization
Inpatient physician or specialist
surgical services
100% (of the negotiated
charge)
No policy year deductible
applies
70% (of the negotiated
charge)
Not covered
Stanford University 2023-2024 Page 19
Eligible health services
Tier 1 (Stanford Health Care,
Menlo Medical Clinic, Sutter
Health) In-network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Outpatient physician or
specialist surgical services
100% (of the negotiated
charge)
No policy year deductible
applies
70% (of the negotiated
charge)
Not covered
Gender affirming treatment
Surgical, hormone replacement
therapy, and counseling
treatment
Covered according to the
Behavioral health section
Covered according to the
Behavioral health section
Not covered
Mental Health & Substance related disorders treatment
Coverage provided under the same terms, conditions as any other illness.
Inpatient hospital
(room and board and other
miscellaneous hospital
services and supplies)
$500 copayment then the
plan pays 100% (of the
negotiated charge) per
admission
100% (of the negotiated
charge) per admission
Not covered
Outpatient office visits
(includes telemedicine
consultations)
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit thereafter
No policy year deductible
applies
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit thereafter
No policy year deductible
applies
Not covered
Other outpatient treatment
(includes skilled behavioral
health services in the home)
100% (of the negotiated
charge) per visit
No policy year deductible
applies
100% (of the negotiated
charge) per visit
No policy year deductible
applies
Not covered
Transplant services
Inpatient and outpatient
transplant facility services
Covered according to the
type of benefit and the place
where the service is received.
Covered according to the
type of benefit and the place
where the service is received.
Not covered
Inpatient and outpatient
transplant physician and
specialist services
Covered according to the
type of benefit and the place
where the service is received.
Covered according to the
type of benefit and the place
where the service is received.
Not covered
Transplant services-travel and
lodging
Covered
Covered
Not applicable
Lifetime Maximum payable for
Travel and Lodging Expenses for
any one transplant, including
tandem transplants
$10,000
$10,000
Not applicable
Maximum payable for Lodging
Expenses per IOE patient
$50 per night
$50 per night
Not applicable
Maximum payable for Lodging
Expenses per companion
$50 per night
$50 per night
Not applicable
Stanford University 2023-2024 Page 20
The following are not covered under this benefit:
•
Services and supplies furnished to a donor when the recipient is not a covered person
•
Harvesting and storage of organs, without intending to use them for immediate transplantation for your existing illness
•
Harvesting and/or storage of bone marrow, hematopoietic stem cells, or other blood cells without intending to use them
for transplantation within 12 months from harvesting, for an existing illness
Eligible health services
Tier 1 (Stanford Health Care,
Menlo Medical Clinic, Sutter
Health) In-network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Treatment of infertility
Basic infertility services Inpatient
and outpatient care - basic
infertility
Covered according to the
type of benefit and the place
where the service is received.
Covered according to the
type of benefit and the place
where the service is received.
Not covered
Comprehensive infertility
services. Inpatient and
outpatient care
50% (of the negotiated charge)
Not covered
Artificial insemination maximum
per policy year
6 attempts
Not applicable
Maximum number of
intrauterine insemination cycles
per policy year
6 attempts
Not applicable
Advanced reproductive
technology (ART) services.
Inpatient and outpatient care
50% (of the negotiated charge)
Not covered
Maximum number of cycles per
policy year
1 course of treatment
Not applicable
Fertility preservation services
Fertility preservation
Covered according to the
type of benefit and the place
where the service is received.
Covered according to the
type of benefit and the place
where the service is received.
Not covered
The following are not covered services under the infertility treatment benefit:
•
Injectable infertility medication, including but not limited to menotropins, hCG, and GnRH agonists.
•
All charges associated with:
-
Surrogacy for you or the surrogate. A surrogate is a female carrying her own genetically related child where the child
is conceived with the intention of turning the child over to be raised by others, including the biological father
-
Thawing of cryopreserved (frozen) eggs, embryos or sperm
-
The care of the donor in a donor egg cycle which includes, but is not limited to, any payments to the donor, donor
screening fees, fees for lab tests, and any charges associated with care of the donor required for donor egg retrievals
or transfers
-
The use of a gestational carrier for the female acting as the gestational carrier. A gestational carrier is a female
carrying an embryo to which the person is not genetically related
-
Obtaining sperm from a person not covered under this plan for ART services
-
Home ovulation prediction kits or home pregnancy tests
-
The purchase of donor embryos, donor oocytes, or donor sperm
-
Reversal of voluntary sterilizations, including follow-up care
•
Ovulation induction with menotropins, Intrauterine insemination and any related services, products or procedures
•
In vitro fertilization (IVF), Zygote intrafallopian transfer (ZIFT), Gamete intrafallopian transfer (GIFT),
Cryopreserved embryo transfers and any related services, products or procedures (such as Intracytoplasmic
Stanford University 2023-2024 Page 21
sperm injection (ICSI) or ovum microsurgery)
•
ART services are not provided for out-of-network care
Eligible health services
Tier 1 (Stanford Health Care,
Menlo Medical Clinic, Sutter
Health) In-network coverage
Tier 2 Aetna In-network
coverage
(IOE facility)
Out-of-network coverage
Specific therapies and tests
Diagnostic complex imaging
services performed in the
outpatient department of a
hospital or other facility
$100 copayment then the
plan pays 100% (of the
negotiated charge) per visit
No policy year deductible
applies
70% (of the negotiated
charge) per visit
Not covered
Diagnostic lab work and
radiological services performed
in a physician’s office, the
outpatient department of a
hospital or other facility
100% (of the negotiated
charge) per visit
No policy year deductible
applies
70% (of the negotiated
charge) per visit
Not covered
Outpatient Chemotherapy,
Radiation & Respiratory Therapy
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit
No policy year deductible
applies
70% (of the negotiated
charge) per visit
Not covered
Outpatient infusion therapy
performed in a covered person’s
home, physician’s office,
outpatient department of a
hospital or other facility
Covered according to the
type of benefit and the place
where the service is received.
Covered according to the
type of benefit and the place
where the service is
received.
Not covered
The following are not covered under this benefit:
•
Enteral nutrition
•
Blood transfusions and blood products
Outpatient Cardiac and
Pulmonary Therapy
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit
No policy year deductible
applies
$40 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit
Not covered
Outpatient physical,
occupational, speech, and
cognitive therapies
Combined for short-term
rehabilitation services and
habilitation therapy services
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit
No policy year deductible
applies
$40 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit
Not covered
Stanford University 2023-2024 Page 22
Eligible health services
Tier 1 (Stanford Health Care,
Menlo Medical Clinic, Sutter
Health) In-network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Acupuncture therapy
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit
No policy year deductible
applies
70% (of the negotiated
charge) per visit, after policy
year deductible
Not covered
The following are not covered under this benefit:
•
Acupressure
Chiropractic services
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit
No policy year deductible
applies
70% (of the negotiated
charge) per visit, after policy
year deductible
Not covered
Maximum visits per policy year
15 visits
Not applicable
Specialty prescription drugs
purchased and injected or
infused by your provider in an
outpatient setting
Covered according to the
type of benefit or the place
where the service is received.
Covered according to the
type of benefit or the place
where the service is received.
Not covered
Other services and supplies
Emergency ground, air, and
water ambulance
(includes non-emergency
ambulance)
100% (of the negotiated
charge) per trip
No policy year deductible
applies
100% (of the negotiated
charge) per trip
No policy year deductible
applies
Paid the same in-network
coverage
Durable medical and surgical
equipment
100% (of the negotiated
charge) per item
No policy year deductible
applies
70% (of the negotiated
charge) per item
Not covered
The following are not covered under this benefit:
•
Whirlpools
•
Portable whirlpool pumps
•
Sauna baths
•
Massage devices
•
Over bed tables
•
Elevators
•
Communication aids
•
Vision aids
•
Telephone alert systems
•
Personal hygiene and convenience items such as air conditioners, humidifiers, hot tubs, or physical exercise
equipment even if they are prescribed by a physician
Stanford University 2023-2024 Page 23
Eligible health services
Tier 1 (Stanford Health Care,
Menlo Medical Clinic, Sutter
Health) In-network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Nutritional support
Covered according to the
type of benefit and the place
where the service is
received.
Covered according to the
type of benefit and the place
where the service is
received.
Not covered
The following are not covered under this benefit:
•
Any food item, including infant formulas, nutritional supplements, vitamins, plus prescription vitamins, medical foods and
other nutritional items, even if it is the sole source of nutrition
Cochlear implants
100% (of the negotiated
charge) per item
No policy year deductible
applies
70% (of the negotiated
charge) per item
Not covered
Prosthetic devices including
contact lenses for aniridia &
Orthotics
100% (of the negotiated
charge) per item
No policy year deductible
applies
70% (of the negotiated
charge) per item
Not covered
The following are not covered under this benefit:
•
Services covered under any other benefit
•
Orthopedic shoes, therapeutic shoes, foot orthotics, or other devices to support the feet, unless required for the
treatment of or to prevent complications of diabetes, or if the orthopedic shoe is an integral part of a covered leg brace
•
Trusses, corsets, and other support items
•
Repair and replacement due to loss or misuse
•
Communication aids
Hearing Exams
Hearing exam
100% (of the negotiated
charge) per visit
No policy year deductible
applies
100% (of the negotiated
charge) per visit
No policy year deductible
applies
Not covered
The following are not covered under this benefit:
•
Hearing exams given during a stay in a hospital or other facility, except those provided to newborns as part of the overall
hospital stay
Pediatric vision care (Limited to covered persons through the end of the month in which the person turns age 19)
Performed by a legally qualified
ophthalmologist or optometrist
(includes comprehensive low
vision evaluations)
100% (of the negotiated
charge) per visit
No policy year deductible
applies
100% (of the negotiated
charge) per visit
No policy year deductible
applies
Not covered
Low vision Maximum
One comprehensive low vision evaluation every five years
Fitting of contact Maximum
1 visit
Not applicable
Stanford University 2023-2024 Page 24
Eligible health services
Tier 1 (Stanford Health Care,
Menlo Medical Clinic, Sutter
Health) In-network coverage
Tier 2 Aetna In-network
coverage
Out-of-network coverage
Pediatric vision care services &
supplies-Eyeglass frames,
prescription lenses or
prescription contact lenses
100% (of the negotiated
charge) per item
No policy year deductible
applies
100% (of the negotiated
charge) per item
No policy year deductible
applies
Not covered
Maximum number Per year:
Eyeglass frames
One set of eyeglass frames
Prescription lenses
One pair of prescription lenses
Contact lenses (includes non-
conventional prescription contact
lenses & aphakic lenses
prescribed after cataract surgery)
Daily disposables: one-year supply
Extended wear disposable: one-year supply
Non-disposable lenses: one-year supply
Not applicable
Optical devices
Covered according to the type of benefit and the place where
the service is received.
Not applicable
Maximum number of optical
devices per policy year
One optical device
Not applicable
*Important note: Refer to the Vision care section in the Certificate for the explanation of these vision care supplies. As to
coverage for prescription lenses in a policy year, this benefit will cover either prescription lenses for eyeglass frames or
prescription contact lenses, but not both.
The following are not covered under this benefit:
•
Eyeglass frames, non-prescription lenses and non-prescription contact lenses that are for cosmetic purposes
Adult vision care Limited to covered persons age 19 and over
Adult routine vision exams
(including refraction) Performed
by a legally qualified
ophthalmologist or therapeutic
optometrist, or any other
providers acting within the scope
of their license
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit
No policy year deductible
applies
$25 copayment then the plan
pays 100% (of the balance of
the negotiated charge) per
visit
No policy year deductible
applies
Not covered
Maximum visits per policy year
1 visit
Not applicable
The following are not covered under this benefit:
Adult vision care
•
Office visits to an ophthalmologist, optometrist or optician related to the fitting of prescription contact lenses
•
Eyeglass frames, non-prescription lenses and non-prescription contact lenses that are for cosmetic purposes
Adult vision care services and supplies
•
Special supplies such as non-prescription sunglasses
•
Special vision procedures, such as orthoptics or vision therapy
•
Eye exams during your stay in a hospital or other facility for health care
•
Eye exams for contact lenses or their fitting
•
Eyeglasses or duplicate or spare eyeglasses or lenses or frames
•
Replacement of lenses or frames that are lost or stolen or broken
•
Acuity tests
•
Eye surgery for the correction of vision, including radial keratotomy, LASIK and similar procedures
•
Services to treat errors of refraction
Stanford University 2023-2024 Page 25
Eligible health services
In-network coverage
Out-of-network coverage
Outpatient prescription drugs
Outpatient prescription drug copayment/coinsurance waiver for risk reducing breast cancer
The per prescription copayment/coinsurance will not apply to risk reducing breast cancer prescription drugs when obtained at a
retail in-network, pharmacy. This means that such risk reducing breast cancer prescription drugs are paid at 100%.
Outpatient prescription drug copayment waiver for tobacco cessation prescription and over-the-counter drugs
The outpatient prescription drug copayment will not apply to treatment regimens per policy year for tobacco cessation
prescription drugs and OTC drugs when obtained at an in-network pharmacy. This means that such prescription drugs and
OTC drugs are paid at 100%.
Outpatient prescription drug copayment waiver for contraceptives
The outpatient prescription drug copayment will not apply to female contraceptive methods when obtained at an in-network
pharmacy.
This means that such contraceptive methods are paid at 100% for:
•
All FDA approved contraceptive prescription drugs and devices, including over-the-counter (OTC) contraceptive prescription
drugs and devices. Related services and supplies needed to administer covered devices will also be paid at 100%.
•
A therapeutic equivalent prescription drug or device when a prescription drug or device is not available or is deemed
medically inadvisable by your provider when you are granted a medical exception.
The Certificate explains how to get a medical exception.
Eligible health services
In-network coverage
Out-of-network coverage
Preferred generic prescription drugs
For each fill up to a 30 day supply
filled at a retail pharmacy
$10 copayment per supply then the plan
pays 100% (of the negotiated charge)
No policy year deductible applies
Not covered
Preferred brand-name prescription drugs
For each fill up to a 30 day supply
filled at a retail pharmacy
$35 copayment per supply then the plan
pays 100% (of the negotiated charge)
No policy year deductible applies
Not covered
Non-preferred generic prescription drugs
For each fill up to a 30 day supply
filled at a retail pharmacy
$50 copayment per supply then the plan
pays 100% (of the negotiated charge)
No policy year deductible applies
Not covered
Non-preferred brand-name prescription drugs
For each fill up to a 30 day supply
filled at a retail pharmacy
$50 copayment per supply then the plan
pays 100% (of the negotiated charge)
No policy year deductible applies
Not covered
Specialty prescription drugs
For each fill up to a 30- day supply
filled at a specialty pharmacy or a
retail pharmacy
$50 copayment per supply then the plan
pays 100% (of the negotiated charge)
No policy year deductible applies
Not covered
Stanford University 2023-2024 Page 26
Eligible health services
In-network coverage
Out-of-network coverage
Contraceptives (birth control)
For each fill up to a 12 month
supply of generic and OTC drugs
and devices filled at a retail
pharmacy
100% (of the negotiated charge)
No policy year deductible applies
Not covered
For each fill up to a 12 month
supply of brand name prescription
drugs and devices filled at a retail
pharmacy
Paid according to the type of drug per the
schedule of benefits, above
A brand name contraceptive is 100% (of
the negotiated charge), No policy year
deductible if there are no generic
therapeutic equivalents.
Not covered
Orally administered anti-cancer
prescription drugs- For each fill up
to a 30 day supply filled at a retail
pharmacy
100% (of the negotiated charge)
No policy year deductible applies
Not covered
Preventive care drugs and
supplements filled at a retail
pharmacy
For each 30 day supply
100% (of the negotiated charge per
prescription or refill
No copayment or policy year deductible
applies
Not covered
Risk reducing breast cancer
prescription drugs filled at a
pharmacy
For each 30 day supply
100% (of the negotiated charge) per
prescription or refill
No copayment or policy year deductible
applies
Not covered
Maximums:
Coverage will be subject to any sex, age,
medical condition, family history, and
frequency guidelines in the
recommendations of the United States
Preventive Services Task Force.
Not applicable
Sexual enhancement or
dysfunction prescription drugs-Up
to 8 pills for each 30 day supply
filled at a retail pharmacy
Paid according to the tier of drug in the
schedule of benefits above
Not covered
Sexual enhancement or
dysfunction prescription drugsUp
to 27 pills for all fills greater than a
30 day supply but no more than a
90 day supply filled at a mail order
pharmacy
Paid according to the tier of drug in the
schedule of benefits above
Not covered
Stanford University 2023-2024 Page 27
Eligible health services
In-network coverage
Out-of-network coverage
Tobacco cessation prescription
and over-the-counter drugs
(Preventive care)-Tobacco
cessation prescription drugs and
OTC drugs filled at a pharmacy
For each 30 day supply
100% (of the negotiated charge per
prescription or refill
No copayment or policy year deductible
applies
Not covered
Maximums:
Coverage will be subject to any sex, age,
medical condition, family history, and
frequency guidelines in the
recommendations of the United States
Preventive Services Task Force.
Not applicable
Outpatient prescription drugs exclusions
The following are not covered under the outpatient prescription drugs benefit:
•
Biological sera unless specified on the preferred drug guide
•
Compounded prescriptions containing bulk chemicals not approved by the U.S. Food and Drug Administration (FDA)
including compounded bioidentical hormones
•
Cosmetic drugs including medications and preparations used for cosmetic purposes
•
Devices, products and appliances, except those that are specially covered
•
Dietary supplements
•
Drugs or medications
-
Which do not, by federal or state law, require a prescription order i.e. over-the-counter (OTC) drugs, even if a
prescription is written except as specifically provided above
-
Not approved by the FDA or not proven safe or effective
-
Provided under your medical plan while an inpatient of a healthcare facility
-
Recently approved by the U.S. Food and Drug Administration (FDA), but which have not yet been reviewed by our
Pharmacy and Therapeutics Committee, unless we have approved a medical exception
-
That include vitamins and minerals unless recommended by the United States Preventive Services Task Force
(USPSTF)
-
For which the cost is covered by a federal, state, or government agency (for example: Medicaid or Veterans
Administration)
-
That are used to treat increase sexual desire, including drugs, implants, devices or preparations to correct or
enhance erectile function, enhance sensitivity, or alter the shape or appearance of a sex organ
-
That are used for the purpose of weight gain or reduction, including but not limited to stimulants, preparations,
foods or diet supplements, dietary regimens and supplements, food or food supplements, appetite suppressants
or other medications
-
That are drugs or growth hormones used to stimulate growth and treat idiopathic short stature unless there is
evidence that the covered person meets one or more clinical criteria detailed in our [precertification] and clinical
policies]
•
Duplicative drug therapy (e.g. two antihistamine drugs)
•
Immunizations related to travel or work
•
Infertility
-
Injectable prescription drugs used primarily for the treatment of infertility
•
Injectables
-
Any charges for the administration or injection of prescription drugs or injectable insulin and other injectable
drugs covered by us.
-
Needles and syringes, except for those used for insulin administration.
-
Any drug which, due to its characteristics, must typically be administered or supervised by a qualified provider or
Stanford University 2023-2024 Page 28
licensed certified health professional in an outpatient setting. This exception does not apply to Depo Provera and
other injectable drugs used for contraception.
•
Off-label drug use except for indications recognized through peer-reviewed medical literature
•
Prescription drugs:
-
That are considered oral dental preparations and fluoride rinses, except pediatric fluoride tablets or drops as
specified on the [preferred] drug guide.
-
That are drugs obtained for use by anyone other than the person identified on the ID card.
•
Replacement of lost or stolen prescriptions
•
Test agents except diabetic test agents
•
A manufacturer’s product when the same or similar drug (that is, a drug with the same active ingredient or same
therapeutic effect), supply or equipment is on the preferred drug guide
•
Any dosage or form of a drug when the same drug is available in a different dosage or form on our preferred drug guide
A covered person, a covered person’s designee or a covered person’s prescriber may seek an expedited medical
exception process to obtain coverage for non-covered drugs in exigent circumstances. An “exigent circumstance” exists
when a covered person is suffering from a health condition that may seriously jeopardize a covered person’s life, health,
or ability to regain maximum function or when a covered person is undergoing a current course of treatment using a
non-formulary drug. The request for an expedited review of an exigent circumstance may be submitted by contacting
Aetna's Precertification Department at 1-855-240-0535, faxing the request to 1-877-269-9916, or submitting the request
in writing to:
CVS Health
ATTN: Aetna PA
1300 E Campbell Road
Richardson, TX 75081
Out of Country claims
Out of Country claims should be submitted with appropriate medical service and payment information from the
provider of service. Covered services received outside the United States will be considered at the Tier 2 In-Network level
of benefits.
Stanford University 2023-2024 Page 29
General Exclusions
Alternative health care
• Services and supplies given by a provider for alternative health care. This includes but is not limited to
aromatherapy, naturopathic medicine, herbal remedies, homeopathy, energy medicine, Christian faith-
healing medicine, Ayurvedic medicine, yoga, hypnotherapy, and traditional Chinese medicine.
Armed forces
• Services and supplies received from a provider as a result of an injury sustained, or illness contracted, while in
the service of the armed forces of any country. When you enter the armed forces of any country, we will refund
any unearned pro-rata premium to the policyholder.
Behavioral health treatment
• Services for the following based on categories, conditions, diagnoses or equivalent terms as listed in the most
recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric
Association:
- Remedial education services that are non-medical and are not medically necessary to treat mental health
disorders or substance use disorders
- Services provided in conjunction with school, vocation, work or recreational activities that are not medically
necessary to treat mental health disorders or substance use disorders
- Sexual deviations and disorders except mental health disorders or substance use disorders listed in the most
recent edition of the DSM and International Classification of Diseases (ICD)
Clinical trial therapies (experimental or investigational)
• Your plan does not cover clinical trial therapies (experimental or investigational), except as described in the
Eligible health services and exclusions- Clinical trial therapies (experimental or investigational) section in the
Certificate
Cosmetic services and plastic surgery
• Any treatment, surgery (cosmetic or plastic), service or supply to alter, improve or enhance the shape or
appearance of the body.
This exclusion does not apply to:
• Surgery after an accidental injury when performed as soon as medically feasible. (Injuries that occur during
medical treatments are not considered accidental injuries even if unplanned or unexpected.)
• Coverage that may be provided under the Eligible health services under your plan - Gender reassignment (sex
change) treatment section.
Court-ordered services and supplies
• This includes court-ordered services and supplies, or those required as a condition of parole, probation, release
or as a result of any legal proceeding, unless they are a covered benefit under your plan
Stanford University 2023-2024 Page 30
Custodial care
Services and supplies meant to help you with activities of daily living or other personal needs.
Examples of these are:
• Routine patient care such as changing dressings, periodic turning and positioning in bed
• Administering oral medications
• Care of a stable tracheostomy (including intermittent suctioning)
• Care of a stable colostomy/ileostomy
• Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings
• Care of a bladder catheter (including emptying/changing containers and clamping tubing)
• Watching or protecting you
• Respite care [except in connection with hospice care], adult (or child) day care, or convalescent care
• Institutional care. This includes room and board for rest cures, adult day care and convalescent care
• Help with walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods
• Any other services that a person without medical or paramedical training could be trained to perform
• Any service that can be performed by a person without any medical or paramedical training
• For behavioral health (mental health treatment and substance use disorders treatment):
- Services provided when you have reached the greatest level of function expected with the current level of
care, for a specific diagnosis
- Services given mainly to:
o Maintain, not improve, a level of function
o Provide a place free from conditions that could make your physical or mental state worse
Dental care for adults
• Dental services for adults including services related to:
- The care, filling, removal or replacement of teeth and treatment of injuries to or diseases of the teeth
- Dental services related to the gums
- Apicoectomy (dental root resection)
- Orthodontics
- Root canal treatment
- Soft tissue impactions
- Alveolectomy
- Augmentation and vestibuloplasty treatment of periodontal disease
- False teeth
- Prosthetic restoration of dental implants
- Dental implants
This exception does not include removal of bony impacted teeth, bone fractures, removal of tumors, and
odontogenic cysts.
Educational services
Examples of these services that are non-medical and are not medically necessary to treat mental health disorders or
substance use disorders are:
• Any service or supply for education, training or retraining services or testing, except where described in the
Eligible health services and exclusions – Diabetic services and supplies (including equipment and training)
section. This includes:
- Special education
- Remedial education
- Job training
- Job hardening programs
Stanford University 2023-2024 Page 31
- Educational services, schooling or any such related or similar program
Examinations
Any health or dental examinations needed:
• Because a third party requires the exam. Examples are, examinations to get or keep a job, or
examinations required under a labor agreement or other contract
• Because a law requires it
• To buy insurance or to get or keep a license
• To travel
• To go to a school, camp, or sporting event, or to join in a sport or other recreational activity
Experimental or investigational
• Experimental or investigational drugs, devices, treatments or procedures unless otherwise covered under clinical
trial therapies (experimental or investigational) or covered under clinical trials (routine patient costs). See the
Eligible health services and exclusions – Other services section in the Certificate.
Facility charges
For care, services or supplies provided in:
• Rest homes
• Assisted living facilities
• Similar institutions serving as a persons’ main residence or providing mainly custodial or rest care
• Health resorts
• Spas or sanitariums
• Infirmaries at schools, colleges, or camps
Felony
• Services and supplies that you receive as a result of an injury due to your commission of a felony
Gene-based, cellular and other innovative therapies (GCIT)
The following are not eligible health services unless you receive prior written approval from us:
• All associated services when GCIT services are not covered. Examples include infusion, laboratory, radiology,
anesthesia, and nursing services.
Please refer to the Medical necessity , referral and precertification requirements section.
Genetic care
• Any treatment, device, drug, service or supply to alter the body’s genes, genetic make-up, or the
expression of the body’s genes except for the correction of congenital birth defects
Growth/Height care
• A treatment, device, service or supply to increase or decrease height or alter the rate of growth
• Surgical procedures and devices to stimulate growth
Hearing aids
Any tests, appliances and devices to:
• Improve your hearing
• Enhance other forms of communication to make up for hearing loss or devices that simulate speech
Stanford University 2023-2024 Page 32
Incidental surgeries
• Charges made by a physician for incidental surgeries. These are non-medically necessary surgeries performed
during the same procedure as a medically necessary surgery.
Judgment or settlement
• Services and supplies for the treatment of an injury or illness to the extent that payment is made as a judgment
or settlement by any person deemed responsible for the injury or illness (or their insurers)
Medical supplies – outpatient disposable
• Any outpatient disposable supply or device. Examples of these are:
- Sheaths
- Bags
- Elastic garments
- Support hose
- Bandages
- Bedpans
- Splints
- Neck braces
- Compresses
- Other devices not intended for reuse by another patient
Non-U.S. citizen
• Services and supplies received by a covered person (who is not a United States citizen) within the covered
person’s home country but only if the home country has a socialized medicine program, except as covered in
the Eligible health services under your plan – Emergency services and urgent care section
Other primary payer
• Payment for a portion of the charge that Medicare or another party pays for as the primary payer
Outpatient prescription or non-prescription drugs and medicines
• Outpatient prescription drugs or non-prescription drugs and medicines provided by the policyholder
Personal care, comfort or convenience items
• Any service or supply primarily for your convenience and personal comfort or that of a third party
Private duty nursing
School health services
• Services and supplies normally provided without charge by the policyholder’s:
- School health services
- Infirmary
- Hospital
- Pharmacy or
by health professionals who
- Are employed by
- Are Affiliated with
- Have an agreement or arrangement with, or
- Are otherwise designated by
Stanford University 2023-2024 Page 33
the policyholder.
Services provided by a family member
• Services provided by a spouse, domestic partner, civil union partner parent, child, step-child, brother,
sister, in-law or any household member
Sexual dysfunction and enhancement
• Any treatment, service, or supply to treat sexual dysfunction, enhance sexual performance or increase sexual
desire, including:
- Implants, devices or preparations to correct or enhance erectile function or sensitivity
- Sex therapy, sex counseling, marriage counseling, or other counseling or advisory services
Sinus surgery
• Any services or supplies given by providers for non-medically necessary sinus surgery except for acute purulent
sinusitis
Strength and performance
• Services, devices and supplies that are not medically necessary, such as drugs or preparations designed
primarily for enhancing your:
- Strength
- Physical condition
- Endurance
- Physical performance
Students in mental health field
• Any services and supplies provided to a covered student who is specializing in the mental health care field and
who receives treatment from a provider as part of their training in that field
Telemedicine
• Services given when you are not present at the same time as the provider
• Services including:
– Telemedicine kiosks
– Electronic vital signs monitoring or exchanges, (e.g. Tele-ICU, Tele-stroke)
Therapies and tests
• Full body CT scans
• Hair analysis
• Hypnosis and hypnotherapy
• Massage therapy, except when used as a physical therapy modality
• Sensory or auditory integration therapy
Treatment in a federal, state, or governmental entity
• Any care in a hospital or other facility owned or operated by any federal, state or other governmental entity,
except to the extent coverage is required by applicable laws
The Stanford University Student Health Insurance Plan is underwritten by Aetna Health and Life Insurance Company.
Aetna Student Health
SM
is the brand name for products and services provided by Aetna Life Insurance Company and its
applicable affiliated companies (Aetna).
Stanford University 2023-2024 Page 34
Sanctioned Countries
If coverage provided by this policy violates or will violate any economic or trade sanctions, the coverage is immediately
considered invalid. For example, Aetna companies cannot make payments for health care or other claims or services if it
violates a financial sanction regulation. This includes sanctions related to a blocked person or a country under sanction
by the United States, unless permitted under a written Office of Foreign Asset Control (OFAC) license. For more
information, visit http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx.
Assistive Technology
Persons using assistive technology may not be able to fully access the following information. For assistance, please call
1-888-843-4708.
Smartphone or Tablet
To view documents from your smartphone or tablet, the free WinZip app is required. It may be available from your App
Store.
Nondiscrimination Notice
Aetna does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender,
gender identity, sexual orientation, age, or disability.
Aetna provides free aids and services to people with disabilities and free language services to people whose primary
language is not English.
These aids and services include:
• Qualified language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Qualified interpreters
• Information written in other languages
If you need these services, have questions about our non-discrimination policy, or have a discrimination-related concern
that you would like to discuss, contact the number on your ID card. Not an Aetna member? Call us at 1-888-843-4708.
If you believe that Aetna has failed to provide these services or discriminated in another way on the basis of race, color,
national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability, you
can file a grievance with our Civil Rights Coordinator at:
• Address: P.O. Box 14462, Lexington, KY 40512 (HMO customers: P.O. Box 24030 Fresno, CA 93779)
• Email: [email protected]
Please visit https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-
appeals.html#california for information about how to file a complaint or grievance with the California Department of
Insurance or California Department of Managed Health Care (for HMO enrollees).
Stanford University 2023-2024 Page 35
You can also file a discrimination complaint with the United States Department of Health and Human Services Office for
Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex by following
the instructions on the Department’s website: https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-
process/index.html
Language accessibility statement
Interpreter services are available for free.
Attention: If you speak English, language assistance service, free of charge, are available to you. Call
1-888-843-4708 (TTY: 711).
Esp
a
ñol/Spanish
Atenció
n: si h
abla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al
1-888-843-4708 (TTY: 711).
አማርኛ
/
Amharic
ልብ ይበሉ: ኣማርኛ ቋንቋ የሚናገሩ ከሆነ፥ የትርጉም ድጋፍ ሰጪ ድርጅቶች፣ ያለምንም ክፍያ እርስዎን ለማገልገል ተዘጋጅተዋል። የሚከተለው ቁጥር ላይ
ይደውሉ 1-888-843-4708 (መስማት ለተሳናቸው: 711).
/Arabic
4708
-888-843-711
1
Ɓ
sɔ
̍
ɔ
̀
W
ɖ/Bassa
D d n k dy
k
dyi s
-w-po-ny
j n
, n
wuu k k po-po
gbo kp
1-888-843-
4708 (TTY: 711).
中文/Chinese
注意：如
果
您说中文，我们可为您提供免费的语言协助服务。请致电 1-888-843-4708 (TTY: 711)。
/Farsi
4708
TTY: 711 1-888-843-
Fran
çai
s/French
Attention : en composant le 1-
888-843-4708 (TTY: 711).
/Gujarati
:
:
. 1-888-843-
4708
(TTY: 711).
Stanfo
rd University 2023-2024
Pa
ge
36
Kreyòl
Ayisyen/H
aitian Creole
Atansyon: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-888-843-4708 (TTY: 711).
Igbo
Nrbama: br na na as Igbo, r enyemaka assr g. Kp 1-888-843-4708 (TTY: 711).
한국어/Korean
주의
: 한
국어를 사용하시는 경우, 언어 지원 서비스가 무료로 제공됩니다. 1-888-843-4708 (TTY: 711)번으로 전화해
주십시오.
Po
r
tuguês/Portuguese
Atenção: a ajuda está disponível em português por meio do número 1-888-843-4708 (TTY: 711). Estes serviços são
oferecidos gratuitamente.
Русский/Russian
1-888-843-4708 (TTY: 711).
Tagalog
Pa
unawa: Ku
ng nagsasalita ka ng Tagalog, maaari kang gumamit ng serbisyo ng tulong sa wika nang walang bayad.
Tumawag sa 1-888-843-4708 (TTY: 711).
/Urdu
711
)
(TTY: 1-888-843-4708 .
Tiếng Việt/Vietnamese
1-888-843-
4708 (TTY: 711).
Yo
rù
bá/Yoruba
kys: B o b , rnl
w
lr èdè, lf
, w f1-888-843-4708 (TTY: 711).
