Stanford Health Care
Advantage - Gold
Advantage - Gold
Stanford Health Care
Advantage - Platinum
Advantage - Platinum
Monthly Premium
$49
$99
Learn More
Comprehensive benefits with extras you need and want
We’ve created two carefully crafted plans for you to choose from. Both plans offer prescription drug coverage and access to our connected team of Stanford Medicine doctors and affiliated network.
The chart below provides a brief summary of our benefits. See our Evidence of Coverage or Summary of Benefits documents for more information.
Benefit Highlights
Out-of-pocket maximum
$4,900
$4,400
Outpatient Services
Outpatient Services
Primary Care Office Visit
$10
$10
Virtual Primary Care Visit
$10
$10
24 Hour Nursing Hotline
$0
$0
Specialist Office Visit
$30
$20
Lab Services
$10
$10
X-ray Services
$45
$25
Diagnostic Tests & Procedures
$45
$45
Comprehensive Dental
(every 6 months)
(every 6 months)
Not covered
Dental PPO
10% of Cost - in -
network cleaning
10% of Cost - in
network x-rays
10% of Cost - in -
network exam
10% of Cost - in -
network cleaning
10% of Cost - in
network x-rays
10% of Cost - in -
network exam
Eye Exams for Glasses
(every year)
(every year)
Not covered
$25
Eyeglass Frames and Lenses
(every 2 years)
(every 2 years)
Not covered
$25
(Up to a maximum benefit of $150)
(Up to a maximum benefit of $150)
Acupuncture
Not covered
$10
(15 visits per year)
(15 visits per year)
Transportation
$0
(24 one-way trips per year)
(24 one-way trips per year)
$0
(24 one-way trips per year)
(24 one-way trips per year)
Hospital and Emergency Care
Hospital and Emergency Care
Inpatient Hospital Care
$250 per day
(Days 1-6)
No charge for the
the remainder of your stay
(Days 1-6)
No charge for the
the remainder of your stay
$200 per day
(Days 1-6)
No charge for the
the remainder of your stay
(Days 1-6)
No charge for the
the remainder of your stay
Skilled Nursing Facility
$0
(Days 1-20)
$150
(Days 21-100)
(Days 1-20)
$150
(Days 21-100)
$0
(Days 1-20)
$100
(Days 21-100)
(Days 1-20)
$100
(Days 21-100)
Outpatient Surgery
$235
$200
Emergency Care
$75
($0 if admitted within 24 hours)
($0 if admitted within 24 hours)
$75
($0 if admitted within 24 hours)
($0 if admitted within 24 hours)
Worldwide Urgent or Emergency Care
Not covered
$75
Up to a maximum of $10,000
Up to a maximum of $10,000
Urgent Care
$35
($0 if admitted within 24 hours)
($0 if admitted within 24 hours)
$35
($0 if admitted within 24 hours)
($0 if admitted within 24 hours)
Prescription Drug Coverage
Prescription Drug Coverage
These plans include Part D prescription drug coverage. The copayments below are for a one month supply of your prescription. Discounts are available for most prescriptions when when you use our mail order service for a three month supply.
Initial Coverage Stage?
Preferred Generics
$2
$2
Non-preferred Generics
$15
$15
Preferred Brand
$47
$47
Non-preferred Brand
$100
$100
Specialty
33% of Cost
33% of Cost
Coverage Gap Stage
Preferred Generics
$2
$2
Non-preferred Generics
$15
$15
Preferred Brand
40% of cost
40% of cost
Non-preferred Brand
51% of cost
51% of cost
Specialty
40% of cost
40% of cost
Catastrophic Coverage Stage
Generics
$3.30 or 5%
(Whichever is higher)
(Whichever is higher)
$3.30 or 5%
(Whichever is higher)
(Whichever is higher)
All Other Drugs
$8.25 or 5%
(Whichever is higher)
(Whichever is higher)
$8.25 or 5%
(Whichever is higher)
(Whichever is higher)
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