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    Content

    Forms and Resources

    For convenient access, download and print the forms and resources that you need.

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    OpenFor Members

    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
    • Pharmacy Mail Order Form
    • *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
    • *View Additional Information About Forms

    CloseFor Members

    OpenFor Brokers

    Broker Forms and Resources

    2021: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21

    • 2021 Individual and Family Plan Application and Enrollment Form
    • 2021 Large Group Enrollment Form
    • 2021 Large Group Employer Application
    • 2021 Small Group Enrollment Form
    • 2021 Small Group Employer Application

    2020: For plans effective 1/1/20 through 12/31/20

    • 2020 Individual and Family Plan Application and Enrollment Form
    • 2020 Large Group Enrollment Form
    • 2020 Large Group Employer Application
    • 2020 Small Group Enrollment Form
    • 2020 Small Group Employer Application

    General Forms

    • Broker Group Submission Checklist
    • Declination of Coverage Form
    • Individual and Family Plans Termination Form
    • Pharmacy Mail Order Form
    • Sole Proprietor, Partner, or Corporate Officer Eligibility Form
    • Termination Form

    Resources

    • 2021 Q1 Small Group Rate Guide
    • 2021 Small Group Optional Benefits Rates
    • 2021 Individual and Family Plan Rate Guide
    • Premium Payment Options

    CloseFor Brokers

    OpenFor Employers

    Employer Forms and Resources

    2021: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21

    • 2021 Large Group Enrollment Form
    • 2021 Large Group Employer Application
    • 2021 Small Group Enrollment Form
    • 2021 Small Group Employer Application

    2020: For plans effective 1/1/20 through 12/31/20

    • 2020 Large Group Enrollment Form
    • 2020 Large Group Employer Application
    • 2020 Small Group Enrollment Form
    • 2020 Small Group Employer Application

    General Forms

    • Declination of Coverage Form
    • Pharmacy Mail Order Form
    • Sole Proprietor, Partner, or Corporate Officer Eligibility Form
    • Termination Form

    Employer Resources

    • Premium Payment Options
    • 2021 Small Group Optional Benefits Rates

    CloseFor Employers

    OpenFor Providers

    Provider Forms and Resources

    • Getting Started with Sutter Health Plus
    • Prescription Drug Prior Authorization Request Form
    • Provider Dispute Form

    CloseFor Providers

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    Additional Resources

    OpenEvidence of Coverage

    Evidence of Coverage

    For more information about Sutter Health Plus’ health plans, you may download and view the Evidence of Coverage for individuals, small and large groups. For assistance or if you have difficulty accessing the information you need, please contact Sutter Health Plus Member Services, weekdays, 8:00 am – 7:00 pm at (855) 315-5800 or TTY: (855) 830-3500.

    2021 LARGE GROUP HMO PLANS: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21

    • 2021 Large Group EOC HDHP HMO
    • 2021 Large Group EOC HMO ML50-51
    • 2021 Large Group EOC HMO ML20 – ML28
    • 2021 Large Group EOC HMO ML29, ML54 and ML56 – ML60

    2021 SMALL GROUP HMO PLANS: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21

    • 2021 Small Group EOC HDHP HMO
    • 2021 Small Group EOC HMO
    • 2021 Small Group EOC Plus HDHP HMO
    • 2021 Small Group EOC Plus HMO

    2021 INDIVIDUAL AND FAMILY PLAN HMO PLANS: FOR PLANS EFFECTIVE 1/1/21 THROUGH 12/31/21

    • 2021 IFP EOC Platinum MI01 HMO
    • 2021 IFP EOC Gold MI02 HMO
    • 2021 IFP EOC Silver MI03 HMO
    • 2021 IFP EOC Bronze MI04 HMO

    2020 Large Group HMO Plans: For Plans Effective 1/1/20 Through 12/31/20

    • 2020 Large Group EOC HMO ML50-51
    • 2020 Large Group EOC HMO ML20 – ML28
    • 2020 Large Group EOC HMO ML29, ML54 and ML56 – ML58
    • 2020 Large Group EOC HDHP HMO

    2020 SMALL GROUP HMO PLANS: FOR PLANS EFFECTIVE 1/1/20 THROUGH 12/31/20

    • 2020 Small Group EOC HMO
    • 2020 Small Group EOC Plus HMO
    • 2020 Small Group EOC HDHP HMO
    • 2020 Small Group EOC Plus HDHP HMO

    2020 INDIVIDUAL AND FAMILY PLAN HMO PLANS: FOR PLANS EFFECTIVE 1/1/20 THROUGH 12/31/20

    • 2020 IFP EOC Platinum MI01 HMO
    • 2020 IFP EOC Gold MI02 HMO
    • 2020 IFP EOC Silver MI03 HMO
    • 2020 IFP EOC Bronze MI04 HMO

    CloseEvidence of Coverage

    OpenSummary of Benefits and Coverage

    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

    • IFP SBC Platinum MI01 HMO
    • IFP SBC Gold MI02 HMO
    • IFP SBC Silver MI03 HMO
    • IFP SBC Bronze MI04 HMO

    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

    • IFP SBC Platinum MI01 HMO
    • IFP SBC Gold MI02 HMO
    • IFP SBC Silver MI03 HMO
    • IFP SBC Bronze MI04 HMO

    CloseSummary of Benefits and Coverage

    OpenBenefits and Coverage Matrix

    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

    • 2021 IFP BCM Platinum MI01 HMO
    • 2021 IFP BCM Gold MI02 HMO
    • 2021 IFP BCM Silver MI03 HMO
    • 2021 IFP BCM Bronze MI04 HMO

    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

    • 2020 IFP BCM Platinum MI01 HMO
    • 2020 IFP BCM Gold MI02 HMO
    • 2020 IFP BCM Silver MI03 HMO
    • 2020 IFP BCM Bronze MI04 HMO

    CloseBenefits and Coverage Matrix

    OpenProduct Portfolio

    Sutter Health Plus Product Portfolio

    2021 Product Portfolio

    • Large Group Plans
    • Small Group Plans
    • Individual and Family Plans
    • Optional Benefit Plans
    • Large Group Underwriting Guidelines
    • Small Group Underwriting Guidelines
    • Individual and Family Plan Underwriting Guidelines

    2020 Product Portfolio

    • Large Group Plans
    • Small Group Plans
    • Individual and Family Plans
    • Optional Benefit Plans
    • Large Group Underwriting Guidelines
    • Small Group Underwriting Guidelines
    • Individual and Family Plan Underwriting Guidelines

    CloseProduct Portfolio

    OpenRate Filing Information

    Rate Filing Information

    • 2020 Individual and Family Plan Rates
    • 2020 First Quarter Small Group Rates
    • 2019 Individual and Family Plan Rates
    • 2019 Fourth Quarter Small Group Rates
    • 2019 First Quarter Small Group Rates
    • 2018 Fourth Quarter Small Group Rates
    • 2018 First Quarter Small Group Rates

    CloseRate Filing Information

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