Forms and Resources
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Member Forms and Resources
Member Forms
- Sutter Health Plus Grievance Form*
- Authorization for Use and Disclosure of Protected Health Information
- Continuity of Care Request Form and Guidelines*
- Coordination of Benefits Form
- Disabled Dependent Certification
- Individual and Family Plans Termination Form
- Member Claim Form
- Opt-Out of Covered CA Sharing
- Prescription Drug Adjustment Request
- Pharmacy Mail Order Form
- Request for Confidential Communication Form
- DMHC Grievance Form for Cancellations, Rescissions and Nonrenewals*
- *View Additional Information About Forms
Member Resources
- Choosing a Primary Care Physician
- Glossary of Terms
- Member Rights and Responsibilities
- Premium Payment Options
- Rights and Protections Against Surprise Medical Bills
- Right to Submit a Grievance, Rescission or Nonrenewal of Your Plan Enrollment, Subscription or Contract*
- Service Area
- Timely Access Standards
- CMS Uniform Glossary (English)
- CMS Uniform Glossary (Spanish)
- World Professional Association for Transgender Health*
- *View Additional Information About Resources
Broker Forms and Resources
2023: FOR PLANS EFFECTIVE 1/1/2023 THROUGH 12/31/2023
2022: FOR PLANS EFFECTIVE 1/1/2022 through 12/31/2022
2021: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21
General Forms
Resources
- Q1 2023 Small Group Rate Guide
- 2023 Individual and Family Plan Rate Guide
- 2023 Small Group Optional Benefit
- 2022 Q4 Small Group Rate Guide
- 2022 Q1 Small Group Rate Guide
- 2022 Small Group Optional Benefits Rates
- 2022 Individual and Family Plan Rate Guide
- 2021 Q1 Small Group Rate Guide
- 2021 Q4 Small Group Rate Guide
- 2021 Small Group Optional Benefits Rates
- 2021 Individual and Family Plan Rate Guide
- Premium Payment Options
- Service Area
Employer Forms and Resources
2023: FOR PLANS EFFECTIVE 1/1/2023 THROUGH 12/31/2023
2022: FOR PLANS EFFECTIVE 1/1/2022 through 12/31/2022
2021: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21
General Forms
Employer Resources
Provider Forms and Resources
Additional Resources
Evidence of Coverage
2022 LARGE GROUP EVIDENCE OF COVERAGE (EOC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22
2022 SMALL GROUP EVIDENCE OF COVERAGE (EOC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22
2022 INDIVIDUAL AND FAMILY PLAN HMO PLANS: FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22
2021 LARGE GROUP HMO PLANS: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21
2021 SMALL GROUP HMO PLANS: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21
Summary of Benefits and Coverage
2022 LARGE GROUP SUMMARY OF BENEFITS AND COVERAGE (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22
- Large Group SBC Summit ML26 HMO
- Large Group SBC Summit ML27 HMO
- Large Group SBC Summit ML28 HMO
- Large Group SBC Summit ML29 HMO
- Large Group SBC Summit ML50 HMO
- Large Group SBC Summit ML51 HMO
- Large Group SBC Summit ML54 HMO
- Large Group SBC Peak ML20 HMO
- Large Group SBC Peak ML21 HMO
- Large Group SBC Peak ML22 HMO
- Large Group SBC Peak ML24 HMO
- Large Group SBC Peak ML25 HMO
- Large Group SBC Peak ML59 HMO
- Large Group SBC Peak ML60 HMO
- Large Group SBC Ridge ML56 HMO
- Large Group SBC Ridge ML57 HMO
- Large Group SBC Ridge ML58 HMO
- Large Group SBC Vista HD08 HDHP HMO
- Large Group SBC Vista HD09 HDHP HMO
- Large Group SBC Vista HD10 HDHP HMO
- Large Group SBC Vista HD15 HDHP HMO
- Large Group SBC Vista HD17 HDHP HMO
- Large Group SBC Vista HD18 HDHP HMO
- Large Group SBC Vista HD19 HDHP HMO
2022 SMALL GROUP SUMMARY OF BENEFITS AND COVERAGE (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22
2022 INDIVIDUAL AND FAMILY PLAN SUMMARY OF BENEFITS AND COVERAGE (SBC): FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22
2021 LARGE GROUP SUMMARY OF BENEFITS AND COVERAGE (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21
- Large Group SBC Summit ML26 HMO
- Large Group SBC Summit ML27 HMO
- Large Group SBC Summit ML28 HMO
- Large Group SBC Summit ML29 HMO
- Large Group SBC Summit ML50 HMO
- Large Group SBC Summit ML51 HMO
- Large Group SBC Summit ML54 HMO
- Large Group SBC Peak ML20 HMO
- Large Group SBC Peak ML21 HMO
- Large Group SBC Peak ML22 HMO
- Large Group SBC Peak ML24 HMO
- Large Group SBC Peak ML25 HMO
- Large Group SBC Peak ML59 HMO
- Large Group SBC Peak ML60 HMO
- Large Group SBC Ridge ML56 HMO
- Large Group SBC Ridge ML57 HMO
- Large Group SBC Ridge ML58 HMO
- Large Group SBC Vista HD08 HDHP HMO
- Large Group SBC Vista HD09 HDHP HMO
- Large Group SBC Vista HD10 HDHP HMO
- Large Group SBC Vista HD15 HDHP HMO
- Large Group SBC Vista HD17 HDHP HMO
- Large Group SBC Vista HD18 HDHP HMO
- Large Group SBC Vista HD19 HDHP HMO
2021 SMALL GROUP SUMMARY OF BENEFITS AND COVERAGE (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21
- Small Group SBC Platinum MS48 HMO
- Small Group SBC Platinum MS41 HMO
- Small Group SBC Platinum MS70 HMO
- Small Group SBC Gold MS67 HMO
- Small Group SBC Gold MS42 HMO
- Small Group SBC Gold MS73 HMO
- Small Group SBC Silver SD47 HDHP HMO
- Small Group SBC Silver MS74 HMO
- Small Group SBC Bronze SD38 HDHP HMO
- Small Group SBC Bronze MS76 HMO
Benefits and Coverage Matrix
2022 LARGE GROUP BENEFITS AND MATRIX (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22
- Large Group BCM Summit ML26 HMO
- Large Group BCM Summit ML27 HMO
- Large Group BCM Summit ML28 HMO
- Large Group BCM Summit ML29 HMO
- Large Group BCM Summit ML50 HMO
- Large Group BCM Summit ML51 HMO
- Large Group BCM Summit ML54 HMO
- Large Group BCM Peak ML20 HMO
- Large Group BCM Peak ML21 HMO
- Large Group BCM Peak ML22 HMO
- Large Group BCM Peak ML24 HMO
- Large Group BCM Peak ML25 HMO
- Large Group BCM Ridge ML59 HMO
- Large Group BCM Ridge ML60 HMO
- Large Group BCM Ridge ML56 HMO
- Large Group BCM Ridge ML57 HMO
- Large Group BCM Ridge ML58 HMO
- Large Group BCM Vista HD08 HDHP HMO
- Large Group BCM Vista HD09 HDHP HMO
- Large Group BCM Vista HD10 HDHP HMO
- Large Group BCM Vista HD15 HDHP HMO
- Large Group BCM Vista HD17 HDHP HMO
- Large Group BCM Vista HD18 HDHP HMO
- Large Group BCM Vista HD19 HDHP HMO
2022 SMALL GROUP BENEFITS AND COVERAGE MATRIX (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22
2022 INDIVIDUAL AND FAMILY PLAN BENEFITS AND COVERAGE MATRIX (BCM): FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22
2021 LARGE GROUP Benefits and Coverage Matrix (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21
- Large Group BCM Summit ML26 HMO
- Large Group BCM Summit ML27 HMO
- Large Group BCM Summit ML28 HMO
- Large Group BCM Summit ML29 HMO
- Large Group BCM Summit ML50 HMO
- Large Group BCM Summit ML51 HMO
- Large Group BCM Summit ML54 HMO
- Large Group BCM Peak ML20 HMO
- Large Group BCM Peak ML21 HMO
- Large Group BCM Peak ML22 HMO
- Large Group BCM Peak ML24 HMO
- Large Group BCM Peak ML25 HMO
- Large Group BCM Peak ML59 HMO
- Large Group BCM Peak ML60 HMO
- Large Group BCM Ridge ML56 HMO
- Large Group BCM Ridge ML57 HMO
- Large Group BCM Ridge ML58 HMO
- Large Group BCM Vista HD08 HDHP HMO
- Large Group BCM Vista HD09 HDHP HMO
- Large Group BCM Vista HD10 HDHP HMO
- Large Group BCM Vista HD15 HDHP HMO
- Large Group BCM Vista HD17 HDHP HMO
- Large Group BCM Vista HD18 HDHP HMO
- Large Group BCM Vista HD19 HDHP HMO
2021 SMALL GROUP BENEFITS AND COVERAGE MATRIX (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21
- Small Group BCM Platinum MS48 HMO
- Small Group BCM Platinum MS41 HMO
- Small Group BCM Platinum MS70 HMO
- Small Group BCM Gold MS67 HMO
- Small Group BCM Gold MS42 HMO
- Small Group BCM Gold MS73 HMO
- Small Group BCM Silver SD47 HDHP HMO
- Small Group BCM Silver MS74 HMO
- Small Group BCM Bronze SD38 HDHP HMO
- Small Group BCM Bronze MS76 HMO
Sutter Health Plus Product Portfolio
2023 Product Portfolio
2022 Product Portfolio
2021 Product Portfolio