2020 San Mateo County Medicare Plans

Comprehensive benefits with extras you need and want

We’ve created two carefully crafted plans for San Mateo County residents 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

Stanford Health Care
Advantage - Gold
Stanford Health Care
Advantage - Platinum

Monthly Premium

$69
$99

Out-of-pocket maximum
$5,900
$4,900

Outpatient Services

Primary Care Office Visit
$10
$10
Virtual Primary Care Visit (Teladoc®)
$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
Not covered
Optional supplemental
benefis available for an
additional premium
Not covered
Optional supplemental
benefis available for an
additional premium
Vision
Not covered
Optional supplemental
benefis available for an
additional premium
Not covered
Optional supplemental
benefis available for an
additional premium
Acupuncture
Not covered
$10
(15 visits per year)
Transportation
$0
(24 one-way trips per year)
$0
(24 one-way trips per year)
Post Discharge Meal Benefit
$0
$0

Hospital and Emergency Care

Inpatient Hospital Care
$275 per day
(Days 1-7)

$0 copay for the
the remainder of your stay
$275 per day
(Days 1-7)

$0 copay for the
the remainder of your stay
Skilled Nursing Facility
$0
(Days 1-20)

$150
(Days 21-100)
$0
(Days 1-20)

$100
(Days 21-100)
Outpatient Surgery
20% coinsurance
$240
Emergency Care
$80
($0 if admitted within 24 hours)
$80
($0 if admitted within 24 hours)
Worldwide emergency
covered with
a $80 copay up to a
maximum of
$10,000 annually
Urgent Care
$35
($0 if admitted within 24 hours)
$35
($0 if admitted within 24 hours)
Worldwide urgent care
covered with
a $35 copay up to a
maximum of
$10,000 annually

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?

Tier 1 Preferred Generics
$5
$5
Tier 2 Non-preferred Generics
$15
$15
Tier 3 Preferred Brand
$47
$47
Tier 4 Non-preferred Brand
$100
$100
Tier 5 Specialty
28% of Cost
33% of Cost
Tier 6 Select Care
$2
$2


Coverage Gap Stage

Tier 1 Preferred Generics
$5 or 25% of cost
(Whichever is lower)
$5 or 25% of cost
(Whichever is lower)
Tier 2 Non-preferred Generics
25% of cost
25% of cost
Tier 3 Preferred Brand
25% of cost
25% of cost
Tier 4 Non-preferred Brand
25% of cost
25% of cost
Tier 5 Specialty
25% of cost
25% of cost
Tier 6 Select Care
$2 or 25% of cost
(Whichever is lower)
$2 or 25% of cost
(Whichever is lower)


Catastrophic Coverage Stage

Generics
$3.60 or 5%
(Whichever is higher)
$3.60 or 5%
(Whichever is higher)
All Other Drugs
$8.95 or 5%
(Whichever is higher)
$8.95 or 5%
(Whichever is higher)

Optional Supplemental Benefits

In addition to the benefits that come with your plan, you can choose to add optional supplemental benefits. These optional supplemental benefits offer dental and vision coverage for an additional monthly premium that is added to your monthly plan premium.

Additional Monthly Premium
$20

Vision Services

WellVision Exam
$25 Copay every calendar year
Prescription Glasses
• Frame (included in prescription glasses)
$150 allowance for a wide selection of frames every other calendar year
• Lenses (included in prescription glasses)
Single vision, lined bifocal, and lined trifocal lenses every other calendar year
Contacts (instead of glasses)
$150 allowance for contacts every other calendar year
$60 maximum copay for contact lens exam (fitting and evaluation) every other calendar year

Comprehensive Dental

• Preventive Service - Initial/routine oral exams, teeth cleaning, fluoride treatment, sealant, x-rays as part of a general exam, nutritional counseling and oral hygiene instructions
$0 copay
• General Services - Fillings, general anesthetics, consultation, palliative treatment of dental pain
$0 - $125 copay
• Major Services - Crowns, removable
and fixed bridges, complete and partial dentures, oral surgery, periodontics, endodontics
$5 - $445 copay

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