Stanford Med · Unit 5B Medicine·Day shift·Mon · 9:42 AM

Insurance plan library

Top 20 Bay Area plans · SNF + HH + behavioral benefits + formulary highlights

Discharge map Dispositions (UB-04)Post-acute services Logistics Needs × coverage Resource hub Insurance plans

The cost-coverage pillar reads from this library when ranking coverage paths + estimating out-of-pocket cost. Each plan is modeled with SNF + Home Health + behavioral benefit summaries + formulary highlights for the highest-leverage post-acute drugs (Entresto, Jardiance, Eliquis, Ozempic, Suboxone, Lantus). Honest depth: tier / copay numbers are accurate-as-of seed date; real-time member-specific lookup needs Surescripts RTBC (Phase 10).

Total plans

Medicare

Medi-Cal

Commercial

Counties covered

all Bay Area

Type

MedicareMedicare Original (Parts A + B)

Centers for Medicare & Medicaid Services · 2025 · counties: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, Sonoma

SNF

20d covered

then $209.5/d

Home Health

Covered

Per medical necessity

Behavioral

In-plan coverage

copay $0/visit

Formulary highlights

Drug	Tier	PA	~Copay
Pembrolizumab (Keytruda)(Oncology (Part B injectable))	T5	yes	$0PAP
Insulin (Part B DME pump)(Diabetes (via insulin pump only))	T2	—	$35PAP

PA standard: 0h · expedited: 0h · verified 2026-05-01

Medicare Adv.Kaiser Permanente Senior Advantage

Kaiser Foundation Health Plan, Inc. · 2025 · counties: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, Sonoma

SNF

20d covered

then $0/d

PA req'd

Home Health

Covered

Per medical necessity

PA req'd

Behavioral

In-plan coverage

copay $20/visit

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$47PAP
Empagliflozin (Jardiance)(T2DM + HFrEF/HFpEF)	T3	—	$47PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$47PAP
Semaglutide (Ozempic)(T2DM)	T3	yes + step	$47PAP
Buprenorphine/naloxone (Suboxone)(Opioid use disorder (MAT))	T2	—	$15
Insulin glargine (Lantus)(Diabetes)	T2	—	$35PAP

PA standard: 72h · expedited: 24h · verified 2026-05-01

Medicare Adv.Stanford Health Care Advantage

Stanford Health Care Advantage (Essence Healthcare admin) · 2025 · counties: Santa Clara, San Mateo

SNF

20d covered

then $25/d

PA req'd

Home Health

Covered

100 visit max

PA req'd

Behavioral

Carved out → Optum Behavioral Health

copay $25/visit

PA req'd

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$47PAP
Empagliflozin (Jardiance)(T2DM + HF)	T3	—	$47PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$47PAP
Pembrolizumab (Keytruda)(Oncology)	T5	yes	$350PAP
Tirzepatide (Mounjaro)(T2DM)	T3	yes + step	$55PAP
Insulin glargine (Lantus)(Diabetes)	T2	—	$35PAP

PA standard: 72h · expedited: 24h · verified 2026-05-01

Medicare Adv.Blue Shield 65 Plus (HMO)

Blue Shield of California · 2025 · counties: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, Sonoma

SNF

20d covered

then $30/d

PA req'd

Home Health

Covered

Per medical necessity

PA req'd

Behavioral

Carved out → Magellan Healthcare

copay $30/visit

PA req'd

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$50PAP
Empagliflozin (Jardiance)(T2DM + HF)	T3	—	$50PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$50PAP
Semaglutide (Ozempic)(T2DM)	T3	yes + step	$50PAP
Buprenorphine/naloxone (Suboxone)(OUD MAT)	T2	—	$15
Insulin glargine (Lantus)(Diabetes)	T2	—	$35PAP

PA standard: 72h · expedited: 24h · verified 2026-05-01

Medicare Adv.UnitedHealthcare AARP Medicare Complete (HMO/PPO)

UnitedHealthcare Insurance Company · 2025 · counties: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, Sonoma

SNF

20d covered

then $20/d

PA req'd

Home Health

Covered

60 visit max

PA req'd

Behavioral

Carved out → Optum Behavioral Health

copay $25/visit

PA req'd

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$45PAP
Empagliflozin (Jardiance)(T2DM + HF)	T3	—	$45PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$45PAP
Semaglutide (Ozempic)(T2DM)	T3	yes + step	$45PAP
Naltrexone ER (Vivitrol)(AUD / OUD MAT)	T3	yes	$75PAP
Pembrolizumab (Keytruda)(Oncology)	T5	yes	$425PAP

PA standard: 72h · expedited: 24h · verified 2026-05-01

Medicare Adv.Brand New Day Classic Choice (HMO)

Brand New Day (Bright Health Group / Molina) · 2025 · counties: Santa Clara, Alameda, Contra Costa

SNF

20d covered

then $0/d

PA req'd

Home Health

Covered

Per medical necessity

PA req'd

Behavioral

In-plan coverage

copay $0/visit

PA req'd

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$40PAP
Empagliflozin (Jardiance)(T2DM + HF)	T3	—	$40PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$40PAP
Buprenorphine/naloxone (Suboxone)(OUD MAT)	T2	—	$10
Insulin glargine (Lantus)(Diabetes)	T2	—	$35PAP

PA standard: 72h · expedited: 24h · verified 2026-05-01

Medicare Adv.Aetna Medicare Premier (PPO)

Aetna Inc. (CVS Health) · 2025 · counties: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, Sonoma

SNF

20d covered

then $25/d

PA req'd

Home Health

Covered

100 visit max

PA req'd

Behavioral

Carved out → Aetna Behavioral Health (internal carve-out)

copay $30/visit

PA req'd

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$47PAP
Empagliflozin (Jardiance)(T2DM + HF)	T3	—	$47PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$47PAP
Tirzepatide (Mounjaro)(T2DM)	T3	yes + step	$50PAP
Buprenorphine/naloxone (Suboxone)(OUD MAT)	T2	—	$15
Insulin glargine (Lantus)(Diabetes)	T2	—	$35PAP

PA standard: 72h · expedited: 24h · verified 2026-05-01

Medi-Cal MCOAnthem Blue Cross Cal MediConnect Plan (D-SNP transition)

Anthem Blue Cross · 2025 · counties: Santa Clara, Alameda, San Mateo

SNF

999d covered

then $0/d

PA req'd

Home Health

Covered

Per medical necessity

PA req'd

Behavioral

Carved out → Santa Clara County Behavioral Health / Alameda County Behavioral Health Care Services / San Mateo BHRS

copay $0/visit

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$0PAP
Empagliflozin (Jardiance)(T2DM + HF)	T3	yes	$0PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$0PAP
Buprenorphine/naloxone (Suboxone)(OUD MAT)	T2	—	$0
Naltrexone ER (Vivitrol)(AUD MAT)	T3	yes	$0PAP
Insulin glargine (Lantus)(Diabetes)	T2	—	$0PAP

PA standard: 120h · expedited: 72h · verified 2026-05-01

Medi-Cal MCOKaiser Permanente Medi-Cal Managed Care

Kaiser Foundation Health Plan, Inc. · 2025 · counties: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, Sonoma

SNF

999d covered

then $0/d

PA req'd

Home Health

Covered

Per medical necessity

PA req'd

Behavioral

Carved out → County Behavioral Health Departments (per Medi-Cal carve-out)

copay $0/visit

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$0PAP
Empagliflozin (Jardiance)(T2DM + HF)	T3	yes	$0PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$0PAP
Buprenorphine/naloxone (Suboxone)(OUD MAT)	T2	—	$0
Insulin glargine (Lantus)(Diabetes)	T2	—	$0PAP

PA standard: 120h · expedited: 72h · verified 2026-05-01

Medi-Cal MCOHealth Net Medi-Cal

Health Net of California (Centene) · 2025 · counties: San Francisco, San Mateo, Santa Clara, Alameda, Contra Costa, Sonoma

SNF

999d covered

then $0/d

PA req'd

Home Health

Covered

Per medical necessity

PA req'd

Behavioral

Carved out → County Behavioral Health Departments

copay $0/visit

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$0PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$0PAP
Buprenorphine/naloxone (Suboxone)(OUD MAT)	T2	—	$0
Naltrexone ER (Vivitrol)(AUD MAT)	T3	yes	$0PAP
Insulin glargine (Lantus)(Diabetes)	T2	—	$0PAP

PA standard: 120h · expedited: 72h · verified 2026-05-01

Medi-Cal MCOSan Francisco Health Plan

San Francisco Health Authority (local public plan) · 2025 · counties: San Francisco

SNF

999d covered

then $0/d

PA req'd

Home Health

Covered

Per medical necessity

PA req'd

Behavioral

Carved out → SF DPH Behavioral Health Services

copay $0/visit

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$0PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$0PAP
Buprenorphine/naloxone (Suboxone)(OUD MAT)	T2	—	$0
Naltrexone ER (Vivitrol)(AUD MAT)	T3	yes	$0PAP
Insulin glargine (Lantus)(Diabetes)	T2	—	$0PAP

PA standard: 120h · expedited: 72h · verified 2026-05-01

Medi-Cal MCOSanta Clara Family Health Plan

Santa Clara County Health Authority · 2025 · counties: Santa Clara

SNF

999d covered

then $0/d

PA req'd

Home Health

Covered

Per medical necessity

PA req'd

Behavioral

Carved out → Santa Clara County Behavioral Health Services Department

copay $0/visit

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$0PAP
Empagliflozin (Jardiance)(T2DM + HF)	T3	yes	$0PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$0PAP
Buprenorphine/naloxone (Suboxone)(OUD MAT)	T2	—	$0
Insulin glargine (Lantus)(Diabetes)	T2	—	$0PAP

PA standard: 120h · expedited: 72h · verified 2026-05-01

Medi-Cal MCOAlameda Alliance for Health

Alameda County Health Authority · 2025 · counties: Alameda

SNF

999d covered

then $0/d

PA req'd

Home Health

Covered

Per medical necessity

PA req'd

Behavioral

Carved out → Alameda County Behavioral Health Care Services

copay $0/visit

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$0PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$0PAP
Buprenorphine/naloxone (Suboxone)(OUD MAT)	T2	—	$0
Naltrexone ER (Vivitrol)(AUD MAT)	T3	yes	$0PAP
Insulin glargine (Lantus)(Diabetes)	T2	—	$0PAP

PA standard: 120h · expedited: 72h · verified 2026-05-01

Medi-Cal MCOContra Costa Health Plan

Contra Costa County (county-operated COHS) · 2025 · counties: Contra Costa

SNF

999d covered

then $0/d

PA req'd

Home Health

Covered

Per medical necessity

PA req'd

Behavioral

Carved out → Contra Costa County Behavioral Health Services

copay $0/visit

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$0PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$0PAP
Buprenorphine/naloxone (Suboxone)(OUD MAT)	T2	—	$0
Insulin glargine (Lantus)(Diabetes)	T2	—	$0PAP

PA standard: 120h · expedited: 72h · verified 2026-05-01

Medi-Cal MCOPartnership HealthPlan of California

Partnership HealthPlan of California (regional COHS) · 2025 · counties: Sonoma, Napa, Marin, Solano

SNF

999d covered

then $0/d

PA req'd

Home Health

Covered

Per medical necessity

PA req'd

Behavioral

Carved out → Sonoma/Napa/Marin/Solano County Behavioral Health Departments

copay $0/visit

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$0PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$0PAP
Buprenorphine/naloxone (Suboxone)(OUD MAT)	T2	—	$0
Naltrexone ER (Vivitrol)(AUD MAT)	T3	yes	$0PAP
Insulin glargine (Lantus)(Diabetes)	T2	—	$0PAP

PA standard: 120h · expedited: 72h · verified 2026-05-01

Commercial PPOAnthem Blue Cross of California PPO

Anthem Blue Cross · 2025 · counties: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, Sonoma

SNF

60d covered

then $250/d

PA req'd

Home Health

Covered

100 visit max

PA req'd

Behavioral

Carved out → Carelon Behavioral Health (Anthem subsidiary)

copay $40/visit

PA req'd

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$75PAP
Empagliflozin (Jardiance)(T2DM + HF)	T3	—	$75PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$75PAP
Semaglutide (Ozempic)(T2DM)	T3	yes + step	$85PAP
Tirzepatide (Mounjaro)(T2DM)	T3	yes + step	$85PAP
Pembrolizumab (Keytruda)(Oncology)	T5	yes	$500PAP
Insulin glargine (Lantus)(Diabetes)	T2	—	$50PAP

PA standard: 72h · expedited: 24h · verified 2026-05-01

Commercial PPOBlue Shield of California PPO

Blue Shield of California · 2025 · counties: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, Sonoma

SNF

60d covered

then $200/d

PA req'd

Home Health

Covered

100 visit max

PA req'd

Behavioral

Carved out → Magellan Healthcare

copay $40/visit

PA req'd

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$70PAP
Empagliflozin (Jardiance)(T2DM + HF)	T3	—	$70PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$70PAP
Semaglutide (Ozempic)(T2DM)	T3	yes + step	$80PAP
Buprenorphine/naloxone (Suboxone)(OUD MAT)	T2	—	$25
Insulin glargine (Lantus)(Diabetes)	T2	—	$50PAP

PA standard: 72h · expedited: 24h · verified 2026-05-01

Commercial HMOKaiser Permanente (Commercial HMO)

Kaiser Foundation Health Plan, Inc. · 2025 · counties: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, Sonoma

SNF

100d covered

then $0/d

PA req'd

Home Health

Covered

Per medical necessity

PA req'd

Behavioral

In-plan coverage

copay $30/visit

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$50PAP
Empagliflozin (Jardiance)(T2DM + HF)	T3	—	$50PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$50PAP
Semaglutide (Ozempic)(T2DM)	T3	yes + step	$50PAP
Buprenorphine/naloxone (Suboxone)(OUD MAT)	T2	—	$20
Insulin glargine (Lantus)(Diabetes)	T2	—	$35PAP

PA standard: 72h · expedited: 24h · verified 2026-05-01

Commercial PPOUnitedHealthcare Choice Plus (Commercial PPO)

UnitedHealthcare Insurance Company · 2025 · counties: Alameda, Contra Costa, San Francisco, San Mateo, Santa Clara, Solano

SNF

60d covered

then $250/d

PA req'd

Home Health

Covered

60 visit max

PA req'd

Behavioral

Carved out → Optum Behavioral Health

copay $40/visit

PA req'd

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$70PAP
Empagliflozin (Jardiance)(T2DM + HF)	T3	—	$70PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$70PAP
Semaglutide (Ozempic)(T2DM)	T3	yes + step	$80PAP
Tirzepatide (Mounjaro)(T2DM)	T3	yes + step	$80PAP
Pembrolizumab (Keytruda)(Oncology)	T5	yes	$500PAP

PA standard: 72h · expedited: 24h · verified 2026-05-01

Commercial PPOStanford Health Care PPO (Employer Direct)

Stanford Health Care (self-insured employer plan administrator) · 2025 · counties: Santa Clara, San Mateo

SNF

60d covered

then $150/d

PA req'd

Home Health

Covered

100 visit max

PA req'd

Behavioral

Carved out → Optum Behavioral Health

copay $30/visit

PA req'd

Formulary highlights

Drug	Tier	PA	~Copay
Sacubitril/valsartan (Entresto)(HFrEF)	T3	yes + step	$60PAP
Empagliflozin (Jardiance)(T2DM + HF)	T3	—	$60PAP
Apixaban (Eliquis)(NVAF / VTE)	T3	—	$60PAP
Tirzepatide (Mounjaro)(T2DM)	T3	yes + step	$75PAP
Pembrolizumab (Keytruda)(Oncology)	T5	yes	$450PAP
Insulin glargine (Lantus)(Diabetes)	T2	—	$40PAP

PA standard: 72h · expedited: 24h · verified 2026-05-01

Demo data · no PHI · mocked Epic + payer endpoints