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
General Forms
Resources
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
General Forms
Employer Resources
Provider Forms and Resources
Additional Resources
Evidence of Coverage
2023 LARGE GROUP EVIDENCE OF COVERAGE (EOC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
2023 SMALL GROUP EVIDENCE OF COVERAGE (EOC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
2023 INDIVIDUAL AND FAMILY PLAN Evidence of Coverage (EOC): FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
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
Summary of Benefits and Coverage
2023 LARGE GROUP SUMMARY OF BENEFITS AND COVERAGE (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
- Large Group SBC Summit ML61 HMO
- Large Group SBC Summit ML62 HMO
- Large Group SBC Summit ML63 HMO
- Large Group SBC Summit ML64 HMO
- Large Group SBC Summit ML65 HMO
- Large Group SBC Summit ML66 HMO
- Large Group SBC Summit ML67 HMO
- Large Group SBC Peak ML68 HMO
- Large Group SBC Peak ML69 HMO
- Large Group SBC Peak ML70 HMO
- Large Group SBC Peak ML71 HMO
- Large Group SBC Peak ML72 HMO
- Large Group SBC Peak ML73 HMO
- Large Group SBC Peak ML77 HMO
- Large Group SBC Ridge ML74 HMO
- Large Group SBC Ridge ML75 HMO
- Large Group SBC Ridge ML76 HMO
- Large Group SBC Vista HD20 HDHP HMO
- Large Group SBC Vista HD21 HDHP HMO
- Large Group SBC Vista HD23H DHP HMO
- Large Group SBC Vista HD24 HDHP HMO
- Large Group SBC Vista HD25 HDHP HMO
- Large Group SBC Vista HD26 HDHP HMO
2023 SMALL GROUP SUMMARY OF BENEFITS AND COVERAGE (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
- Small Group SBC Platinum MS68 HMO
- Small Group SBC Platinum MS80 HMO
- Small Group SBC Gold MS77 HMO
- Small Group SBC Gold SD02 HDHP HMO
- Small Group SBC Gold MS62 HMO
- Small Group SBC Gold MS83 HMO
- Small Group SBC Silver SD01 HDHP HMO
- Small Group SBC Silver MS84 HMO
- Small Group SBC Bronze SD48 HDHP HMO
- Small Group SBC Bronze MS86 HMO
2023 INDIVIDUAL AND FAMILY PLAN SUMMARY OF BENEFITS AND COVERAGE: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
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
Benefits and Coverage Matrix
2023 LARGE GROUP BENEFITS AND MATRIX (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
- Large Group BCM Summit ML61 HMO
- Large Group BCM Summit ML62 HMO
- Large Group BCM Summit ML63 HMO
- Large Group BCM Summit ML64 HMO
- Large Group BCM Summit ML65 HMO
- Large Group BCM Summit ML66 HMO
- Large Group BCM Summit ML67 HMO
- Large Group BCM Peak ML68 HMO
- Large Group BCM Peak ML69 HMO
- Large Group BCM Peak ML70 HMO
- Large Group BCM Peak ML71 HMO
- Large Group BCM Peak ML72 HMO
- Large Group BCM Peak ML73 HMO
- Large Group BCM Peak ML77 HMO
- Large Group BCM Ridge ML74 HMO
- Large Group BCM Ridge ML75HMO
- Large Group BCM Ridge ML76 HMO
- Large Group BCM Vista HD20 HDHP HMO
- Large Group BCM Vista HD21 HDHP HMO
- Large Group BCM Vista HD22 HDHP HMO
- Large Group BCM Vista HD23 HDHP HMO
- Large Group BCM Vista HD24 HDHP HMO
- Large Group BCM Vista HD25 HDHP HMO
- Large Group BCM Vista HD26 HDHP HMO
2023 SMALL GROUP BENEFITS AND COVERAGE MATRIX (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
- Small Group BCM Platinum MS68 HMO
- Small Group BCM Platinum MS80 HMO
- Small Group BCM Gold MS77 HMO
- Small Group BCM Gold SD02 HDHP HMO
- Small Group BCM Gold MS62 HMO
- Small Group BCM Gold MS83 HMO
- Small Group BCM Silver SD01 HDHP HMO
- Small Group BCM Silver MS84 HMO
- Small Group BCM Bronze SD48 HDHP HMO
- Small Group BCM Bronze MS86 HMO
2023 INDIVIDUAL AND FAMILY PLAN BENEFITS AND COVERAGE MATRIX (BCM): FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
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
Sutter Health Plus Product Portfolio
2023 Product Portfolio
2022 Product Portfolio