Stanford Health Care Advantage
Platinum (HMO) Plan

Complete Coverage With One Plan From One Company

Unlike traditional Medicare, Stanford Health Care Advantage bundles your medical, hospital and prescription drug coverage together in one comprehensive plan. The plan comes with valuable extra benefits that save you even more.

Low Copay on Generic Prescriptions

Save even more money on your prescription drugs when you fill your prescription at pharmacies. Stanford Health Care Advantage Platinum (HMO) members can get generic prescriptions for low copays and reduced copays on brand-name medications at participating pharmacies.

Important Financial Protection

Stanford Health Care Advantage protects your savings and retirement by putting an annual limit on what you have to pay out of your own pocket for your covered medical expenses—important protection not offered by Original Medicare plans.

Valuable Extra Benefits That Save You Money

Every Stanford Health Care Advantage plan comes with important extra benefits for no additional premium including prescription drug coverage, hearing benefits, acupuncture and transportation to and from doctor appointments. Plus, members have the option to add dental and vision coverage.


Benefits at a Glance:
We Have Got You Covered From Head to Toe

The following table highlights just some of the many in-network benefits available to you as a valued Stanford Health Care Advantage member. For more details and a complete list of benefits, please review our Summary of Benefits or Evidence of Coverage which can be downloaded by clicking the links below.

Medical & Hospital Coverage

Your Stanford Health Care Advantage plan provides comprehensive medical and hospital coverage with no annual deductible and low copayments for in-network providers.

Stanford Health Care Advantage Platinum (HMO)
Monthly Premium $99
Maximum Out-of-Pocket Limit (What’s this?)This means you will never pay more than $5,250 per year for covered medical expenses, even if you have an unexpected illness or injury. If you reach this limit, you will no longer have to pay any copays or coinsurance. $5,250 Per Year
Annual Medical Deductible $0 Per Year
Preventive Care/Screenings $0 Copay
Primary Care Physician Visits $10 Copay
Specialist Doctor Visits $30 Copay
Urgent Care $35 Copay
Emergency Care $80 Copay
Lab Services $10 Copay
Home Health Care 100% Coverage
Chiropractic Services $20 Copay
Inpatient Hospital Care $275 Copay Per Day for Days 1-7,
$0 Per Day for Days 8 and beyond
Outpatient Surgery at Hospital $240 Copay
Outpatient Surgery at Ambulatory Surgical Center $240 Copay

Part D Drug Coverage

This table shows the drug tiers associated with your plan, and the copayments or co insurance that you will pay in each tier. A drug formulary provides a list of drugs that are covered by our plan.

Stanford Health Care Advantage Platinum (HMO)
Participating
Pharmacies
Annual Part D Deductible $0 Per Year
Tier 1 – Preferred Generics $5 Copay
Tier 2 – Generics $15 Copay
Tier 3 – Preferred Brands $47 Copay
Tier 4 – Non-Preferred Brands $100 Copay
Tier 5 – Specialty Drugs 33% Coinsurance
Tier 6 – Select Care $2 Copay
Initial Coverage Limit $4,130 Per Year

Part D drug expenses are not covered under the maximum out-of-pocket limit. 


Extra Benefits

Your Stanford Health Care Advantage plan offers many valuable extras not offered by Original Medicare or Medicare supplement plans–at no additional cost to you.

Stanford Health Care Advantage Platinum (HMO)
Hearing $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
Silver&Fit® Included at no additional cost
Travel Coverage Emergency or urgent care coverage if you are making a trip out of state or country

Extra benefit expenses are not covered under the maximum out-of-pocket limit.


Important Plan Documents

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