Forms and Resources
For convenient access, download and print the forms and resources that you need.
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
- Pharmacy Mail Order 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
- Right to Submit a Grievance, Rescission or Nonrenewal of Your Plan Enrollment, Subscription or Contract*
- Timely Access Standards
- CMS Uniform Glossary (English)
- CMS Uniform Glossary (Spanish)
- *View Additional Information About Resources
Broker Forms and Resources
2021: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21
2020: For plans effective 1/1/20 through 12/31/20
General Forms
Resources
Employer Forms and Resources
2021: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21
2020: For plans effective 1/1/20 through 12/31/20
General Forms
Employer Resources
Provider Forms and Resources
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Additional Resources
Evidence of Coverage
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
2021 INDIVIDUAL AND FAMILY PLAN HMO PLANS: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21
2020 Large Group HMO Plans: For Plans Effective 1/1/20 Through 12/31/20
2020 SMALL GROUP HMO PLANS: FOR PLANS EFFECTIVE 1/1/20 THROUGH 12/31/20
2020 INDIVIDUAL AND FAMILY PLAN HMO PLANS: FOR PLANS EFFECTIVE 1/1/20 THROUGH 12/31/20
Summary of Benefits and Coverage
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
2021 INDIVIDUAL AND FAMILY PLAN SUMMARY OF BENEFITS AND COVERAGE (SBC): FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21
2020 LARGE GROUP Summary of Benefits and Coverage (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/20 THROUGH 12/31/20
- 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 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 HD18 HDHP HMO
- Large Group SBC Vista HD19 HDHP HMO
2020 SMALL GROUP Summary of Benefits and Coverage (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/20 THROUGH 12/31/20
- Small Group SBC Platinum MS38 HMO
- Small Group SBC Platinum MS41 HMO
- Small Group SBC Platinum MS60 HMO
- Small Group SBC Gold MS57 HMO
- Small Group SBC Gold MS42 HMO
- Small Group SBC Gold MS63 HMO
- Small Group SBC Silver SD37 HMO
- Small Group SBC Silver MS64 HMO
- Small Group SBC Bronze SD28 HMO
- Small Group SBC Bronze MS66 HMO
2020 INDIVIDUAL AND FAMILY PLAN Summary of Benefits and Coverage (SBC): FOR PLANS EFFECTIVE 1/1/20 THROUGH 12/31/20
Benefits and Coverage Matrix
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
2021 INDIVIDUAL AND FAMILY PLAN Benefits and Coverage Matrix (BCM): FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21
2020 LARGE GROUP Benefits and Coverage Matrix (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/20 THROUGH 12/31/20
- 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 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 HD18 HDHP HMO
- Large Group BCM Vista HD19 HDHP HMO
2020 SMALL GROUP Benefits and Coverage Matrix (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/20 THROUGH 12/31/20
- Small Group BCM Platinum MS38 HMO
- Small Group BCM Platinum MS41 HMO
- Small Group BCM Platinum MS60 HMO
- Small Group BCM Gold MS57 HMO
- Small Group BCM Gold MS42 HMO
- Small Group BCM Gold MS63 HMO
- Small Group BCM Silver SD37 HMO
- Small Group BCM Silver MS64 HMO
- Small Group BCM Bronze SD28 HMO
- Small Group BCM Bronze MS66 HMO
2020 INDIVIDUAL AND FAMILY PLAN Benefits and Coverage Matrix (BCM): FOR PLANS EFFECTIVE 1/1/20 THROUGH 12/31/20
Sutter Health Plus Product Portfolio
2021 Product Portfolio
2020 Product Portfolio