Summary of Benefits
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The following tables summarize the Cardinal Care 2024-2025 medical, mental health, and dental benefits. A full list of covered services and complete description of plan definitions and exclusions can be found in the applicable Plan Design and Benefits Summary at the Aetna website.
Summary of Cardinal Care Medical Benefits*
| Plan Provision | TIER 1 Stanford University Medical Center, Menlo Medical Clinic, and Sutter Health | TIER 2 All Other Aetna Participating Network Providers |
|---|---|---|
| Annual deductible | $100 (applies to inpatient admissions, outpatient surgery, and infertility treatment) | $500 (applies to all services) |
| Annual out-of-pocket maximum (Excludes some family planning services, expenses related to noncertified services, and services not covered under the plan.) | $2,000 | $4,000 |
| Lifetime maximum for medical coverage | Unlimited | Unlimited |
| Preventive care (Preventive care includes services that have been identified as preventive in the following areas: annual exams, vision/hearing screenings, newborn and well-woman care, and lab and x-ray services.) | $0 out of pocket (deductible waived) | $0 out of pocket (deductible waived) |
| Emergency and urgent care services | ||
| Emergency room | $100 copay per visit (waived if admitted) | $100 copay per visit (waived if admitted) |
| Urgent care | $50 copay | $50 copay |
| Surgery | ||
| Surgeon or assistant surgeon service | 100% covered | 70% covered after the plan year deductible has been met |
| Outpatient surgery/procedure | $250 copay after the plan year deductible has been met | 70% covered after the plan year deductible has been met |
| Hospital and skilled nursing facility stays Semiprivate inpatient hospital room or intensive care unit with ancillary services (includes acute care detoxification admissions) | 100% covered after a $500 copay per admission and after you meet the plan-year deductible | 70% covered after the plan year deductible has been met |
| Primary care physician office visit | No point of service charge if provided by Vaden Health Center $25 copay for services provided outside Vaden Health Center | No point of service charge if provided by Vaden Health Center $25 copay for services provided outside Vaden Health Center (deductible waived) |
| Outpatient specialist and consultant visits | 100% covered after a $25 copay for each visit | 70% covered after the plan year deductible has been met |
| Rehabilitative therapy (including physical, speech, occupational, respiratory and cardiac therapy) | 100% covered after a $25 copay for each visit | 100% covered after a $40 copay for each visit (deductible applies) |
| Rehabilitative therapy (Chiropractor and Acupuncture) | 100% covered after a $25 copay for each visit | 100% covered after a 40% copay for each visit (deductible waived) |
| General medical services | ||
| Chemotherapy/radiation therapy/nuclear medicine (professional service only) | 100% covered after a $25 copay for each visit | 70% covered after the plan year deductible has been met |
| Organ transplants (nonexperimental and noninvestigational) | 100% covered after the plan year deductible has been met | 70% covered after the plan year deductible has been met |
| X-ray (excluding complex radiology) | 100% covered | 70% covered after the plan year deductible has been met |
| Laboratory | 100% covered | 100% covered after a $25 copay (deductible waived) |
| Complex radiology (e.g., MRI, CT, PET, SPECT, MUGA, ultrasound) | 100% covered after two $100 copays (professional and technical charges) per service (outpatient setting) OR 100% covered after the plan year deductible has been met (inpatient setting) | 70% covered after the plan year deductible has been met |
| Durable Medical Equipment (DME) | 100% covered (of the negotiated charge per item) (deductible waived) | 100% covered after a $25 copay |
| Pregnancy and maternity care | ||
| Normal delivery, cesarean section and complications of pregnancy | 100% covered after the $100 annual deductible has been met and a $500 copay (per admission) has been applied | 70% covered after the plan year deductible has been met |
| Prenatal office visits | 100% covered | 70% covered after the plan year deductible has been met |
| Postnatal office visits | 100% covered after a $25 copay for each visit | 70% covered after the plan year deductible has been met |
| Genetic testing of fetus | 100% covered | 70% covered after the plan year deductible has been met |
| Reproductive health | ||
| Infertility (comprehensive infertility services) | 50% covered after you meet the plan year deductible has been met | 50% covered after the plan year deductible has been met |
| Female Sterilization | 100% covered (deductible waived) | 100% covered (deductible waived) |
| Male Sterilization | 100% covered after a $50 copay | 100% covered after a $100 copay (deductible applies) |
| Annual refractive eye exam | 100% covered after a $25 copay | 100% covered after a $25 copay |
| Prescriptions filled at Walgreens at Vaden or another preferred Aetna Student HealthSM pharmacy | $10 copay for generic drugs $35 copay for brand formulary drugs $50 copay for brand non-formulary and specialty drugs | $10 copay for generic drugs $35 copay for brand formulary drugs $50 copay for brand non-formulary and specialty drugs |
Summary of Cardinal Care Mental Health Benefits*
| Mental and Substance Use Disorder Treatment | Tier 1 | Tier 2 |
|---|---|---|
| Outpatient treatment | $25 copay per visit | $25 copay per visit |
| Inpatient treatment in a hospital or residential facility | 100% covered after a $250 copay per admission | 100% covered after the plan year deductible has been met |
| Other outpatient treatment (includes physical, occupational, speech, cognitive therapies and 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 |
* For complete information, refer to the Plan Design and Benefits Summary.
Summary of Cardinal Care Dental Benefits*
Eligibility
- Students enrolled in Cardinal Care and
- Dependents enrolled in Dependent Care
Deductibles
- Aetna PPO Dental dentists: $25 each plan year
- Non-Aetna-PPO-Dental dentists: $50 each plan year
- Deductibles waived for diagnostic and preventive dental care? Yes.
Maximum Benefit
- Aetna PPO Dental dentists: $1,000 each plan year
- Non-Aetna-PPO-Dental dentists: $1,000 each plan year
- Waiting Period for Basic Benefits: None
| Benefits and Covered Services | Aetna PPO Dental Dentists | Non-Aetna-PPO-Dental Dentists |
|---|---|---|
| Diagnostic and Preventive Services Exams, cleanings, x-rays and sealants | 100% covered | 50% covered |
| Basic Services Fillings and simple extractions | 80% covered | 50% covered |
| Endodontics (root canals) Covered under Basic Services | 80% covered | 50% covered |
| Periodontics (gum treatment) Covered under Basic Services | 80% covered | 50% covered |
| Oral Surgery (including impacted tooth) | 80% covered | 50% covered |
| Major Services Crowns, inlays, onlays and cast restorations | Not covered | Not covered |
| Prosthodontics Bridges and dentures | Not covered | Not covered |
* For complete information, refer to the Dental Plan Design and Benefits Summary.
International Coverage
Cardinal Care provides coverage for care rendered outside the United States. In most instances, payment must be made to the provider directly at the time of service. Students can then seek reimbursement from Aetna, which will occur under Tier 2.
