Stanford Health Care Advantage (HMO) Plans in Your Area

Stanford Health Care Advantage
Gold (HMO)
Stanford Health Care Advantage
Platinum (HMO)
Hospital & Medical
Monthly Premium$69$99
Maximum Out-of-Pocket Limit$6,500 Per Year$5,250 Per Year
Annual Deductible$0$0
Preventive Care/Screenings$0 Copay$0 Copay
Primary Care Physician Visits$10 Copay$10 Copay
Specialist Doctor Visits$30 Copay$20 Copay
Urgent Care$35 Copay$35 Copay
Emergency Care$80 Copay$80 Copay
Lab Services$10 Copay$10 Copay
Home Health Care100% Coverage100% Coverage
Medicare-Covered Chiropractic Care$20 Copay$20 Copay
Inpatient Hospital$275 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
$275 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
Outpatient Surgery at Hospital20% Coinsurance$240 Copay
Outpatient Surgery at Ambulatory Surgery Center20% Coinsurance$240 Copay
Part D Prescription Drug Coverage
Annual Deductible
  • Participating Pharmacies - $250
    (applies to Tiers 3, 4, and 5)
  • Participating Pharmacies - $0
Tier 1
Preferred Generics
  • Participating Pharmacies - $5 Copay
  • Participating Pharmacies - $5 Copay
Tier 2
Non-Preferred Generics
  • Participating Pharmacies - $15 Copay
  • Participating Pharmacies - $15 Copay
Tier 3
Preferred Brand Names
  • Participating Pharmacies - $47 Copay
  • Participating Pharmacies - $47 Copay
Tier 4
Non-Preferred Brand Names
  • Participating Pharmacies - $100 Copay
  • Participating Pharmacies - $100 Copay
Tier 5
Specialty Drugs
  • Participating Pharmacies - 28% Co-insurance
  • Participating Pharmacies - 33% Co-insurance
Tier 6
Select Care
  • Participating Pharmacies - $2 Copay
  • Participating Pharmacies - $2 Copay
Mail Order
90-Day Supply
$10, $30, $94, $200, $4$10, $30, $94, $200, $4
Initial Coverage Limits
  • Participating Pharmacies - $4,130
  • Participating Pharmacies - $4,130
What Medications are Covered
Extra Benefits
Hearing$0 Copay per Medicare-covered visit
Hearing aids and fitting not covered
$0 Copay per Medicare-covered visit
Hearing aids and fitting not covered
Transportation Assistance$0 Copay for 24 one-way trips to approved locations per year$0 Copay for 24 one-way trips to approved locations per year
Silver&Fit®Not coveredIncluded at no additional cost

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