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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
    • 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
    • View Additional Information About Forms

    CloseFor Members

    OpenFor Brokers

    Broker Forms and Resources

    2023: FOR PLANS EFFECTIVE 1/1/2023 THROUGH 12/31/2023

    • 2023 Individual and Family Plan Application and Enrollment Form
    • 2023 Large Group Enrollment Form
    • 2023 Large Group Employer Application
    • 2023 Small Group Employer Application
    • 2023 Small Group Enrollment Form

    2022: FOR PLANS EFFECTIVE 1/1/2022 through 12/31/2022

    • 2022 Individual and Family Plan Application and Enrollment Form
    • 2022 Large Group Employer Application
    • 2022 Large Group Enrollment Form
    • 2022 Small Group Employer Application
    • 2022 Small Group Enrollment Form

    General Forms

    • Large Group Submission Checklist
    • Small Group Submission Checklist
    • Declination of Coverage Form
    • Individual and Family Plans Termination Form
    • Pharmacy Mail Order Form
    • Eligibility Form
    • Termination Form

    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
    • Premium Payment Options
    • Service Area
    • Sutter Health Plus CSV File Template

    CloseFor Brokers

    OpenFor Employers

    Employer Forms and Resources

    2023: FOR PLANS EFFECTIVE 1/1/2023 THROUGH 12/31/2023

    • 2023 Large Group Enrollment Form
    • 2023 Large Group Employer Application
    • 2023 Small Group Employer Application
    • 2023 Small Group Enrollment Form

    2022: FOR PLANS EFFECTIVE 1/1/2022 through 12/31/2022

    • 2022 Large Group Employer Application
    • 2022 Large Group Enrollment Form
    • 2022 Small Group Employer Application
    • 2022 Small Group Enrollment Form

    General Forms

    • Declination of Coverage Form
    • OTC COVID-19 Testing Reimbursement for Schools or Employers Form
    • Pharmacy Mail Order Form
    • Eligibility Form
    • Termination Form
    • Premium Reporting Form

    Employer Resources

    • Q1 2023 Small Group Rate Guide
    • 2023 Small Group Optional Benefit
    • Premium Payment Options
    • Service Area
    • 2022 Q4 Small Group Rate Guide
    • 2022 Small Group Optional Benefits Rates
    • 2022 Q1 Small Group Rate Guide
    • Sutter Health Plus CSV File Template

    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

    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.

    2023 LARGE GROUP EVIDENCE OF COVERAGE (EOC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23

    • 2023 Large Group EOC HDHP HMO
    • 2023 Large Group EOC HMO ML65 and ML66
    • 2023 Large Group EOC HMO ML61-63, ML68-72
    • 2023 Large Group EOC HMO ML64, ML67, and ML73-77

    2023 SMALL GROUP EVIDENCE OF COVERAGE (EOC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23

    • 2023 Small Group EOC HDHP HMO
    • 2023 Small Group EOC HMO
    • 2023 Small Group EOC Plus HDHP HMO
    • 2023 Small Group EOC Plus HMO

    2023 INDIVIDUAL AND FAMILY PLAN Evidence of Coverage (EOC): FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23

    • 2023 IFP EOC Platinum MI01 HMO
    • 2023 IFP EOC Gold MI02 HMO
    • 2023 IFP EOC Silver MI03 HMO
    • 2023 IFP EOC Bronze MI04 HMO

    2022 LARGE GROUP EVIDENCE OF COVERAGE (EOC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22

    • 2022 Large Group EOC HDHP HMO
    • 2022 Large Group EOC HMO ML50-51
    • 2022 Large Group EOC HMO ML20 – ML28
    • 2022 Large Group EOC HMO ML29, ML54 and ML56 – ML60

    2022 SMALL GROUP EVIDENCE OF COVERAGE (EOC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22

    • 2022 Small Group EOC HDHP HMO
    • 2022 Small Group EOC HMO
    • 2022 Small Group EOC Plus HDHP HMO
    • 2022 Small Group EOC Plus HMO

    2022 INDIVIDUAL AND FAMILY PLAN HMO PLANS: FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22

    • 2022 IFP EOC Platinum MI01 HMO
    • 2022 IFP EOC Gold MI02 HMO
    • 2022 IFP EOC Silver MI03 HMO
    • 2022 IFP EOC Bronze MI04 HMO

    CloseEvidence of Coverage

    OpenSummary of Benefits and Coverage

    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

    • 2023 IFP SBC Platinum MI01 HMO
    • 2023 IFP SBC Gold MI02 HMO
    • 2023 IFP SBC Silver MI03 HMO
    • 2023 IFP SBC Bronze MI04 HMO

    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

    • Small Group SBC Platinum MS58 HMO
    • Small Group SBC Platinum MS70 HMO
    • Small Group SBC Gold MS67 HMO
    • Small Group SBC Gold MS52 HMO
    • Small Group SBC Gold MS73 HMO
    • Small Group SBC Silver SD47 HMO
    • Small Group SBC Silver MS74 HMO
    • Small Group SBC Bronze SD38 HMO
    • Small Group SBC Bronze MS76 HMO

    2022 INDIVIDUAL AND FAMILY PLAN SUMMARY OF BENEFITS AND COVERAGE (SBC): FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22

    • 2022 IFP SBC Platinum MI01 HMO
    • 2022 IFP SBC Gold MI02 HMO
    • 2022 IFP SBC Silver MI03 HMO
    • 2022 IFP SBC Bronze MI04 HMO

    CloseSummary of Benefits and Coverage

    OpenBenefits and Coverage Matrix

    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

    • 2023 IFP BCM Platinum MI01 HMO
    • 2023 IFP BCM Gold MI02 HMO
    • 2023 IFP BCM Silver MI03 HMO
    • 2023 IFP BCM Bronze MI04 HMO

    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

    • Small Group BCM Platinum MS58 HMO
    • Small Group BCM Platinum MS70 HMO
    • Small Group BCM Gold MS67 HMO
    • Small Group BCM Gold MS52 HMO
    • Small Group BCM Gold MS73 HMO
    • Small Group BCM Silver SD47 HMO
    • Small Group BCM Silver MS74 HMO
    • Small Group BCM Bronze SD38 HMO
    • Small Group BCM Bronze MS76 HMO

    2022 INDIVIDUAL AND FAMILY PLAN BENEFITS AND COVERAGE MATRIX (BCM): FOR PLANS EFFECTIVE 1/1/22 THROUGH 12/31/22

    • 2022 IFP BCM Platinum MI01 HMO
    • 2022 IFP BCM Gold MI02 HMO
    • 2022 IFP BCM Silver MI03 HMO
    • 2022 IFP BCM Bronze MI04 HMO

    CloseBenefits and Coverage Matrix

    OpenProduct Portfolio

    Sutter Health Plus Product Portfolio

    2023 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

    2022 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

    • 2022 First Quarter Small Group Rates
    • 2022 First Quarter Individual and Family Plan Rates
    • 2021 Fourth Quarter Small Group Rates
    • 2021 First Quarter Small Group Rates
    • 2021 First Quarter Individual and Family Plan Rates
    • 2020 Individual and Family Plan Rates
    • 2020 First Quarter Small Group Rates

    CloseRate Filing Information

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