Human Resources Benefits Unit

Sutter Health Plus Deductible First HDHP

The Sutter Health Plus HDHP HD01/51 offers a lower monthly premium and higher deductible limits than the two other Sutter Health Plus HMO plans. After a member meets the deductible, the plan pays for a percentage of medical care until the member reaches the annual out-of-pocket maximum.

Deductible First HD01/HD51 $20 copay per visit for primary care and specialist visits after the deductibles met. Prescription medications are available through retail or mail order at a copay range of $10 - $120 after the deductible is met. Tier 4 prescription medications are covered at a 20% coinsurance, not to exceed $100 per prescription after the deductible is met.

Employees who have an HRA (Health Reimbursement Arrangement), or an FSA (Flexible Spending Account), may submit Sutter Health Plus out-of-pocket expenses for reimbursement.

Take Note… If you (the employee) elect to enroll in this Deductible First HDHP, which qualifies as an HSA-qualified high deductible health plan, and you have a Flexible Spending Account and/or a Health Reimbursement Arrangement (HRA), be advised that under IRS rules you are NOT allowed to contribute to a Health Savings Account (HSA). Because FSA and HRA accounts can be used to reimburse your out-of-pocket medical expenses, the IRS does not allow you to also contribute to a Health Savings Account at the same time, as it is considered prohibited health coverage.

Plan InformationSutter Health Plus Deductible First HDHP
Calendar Year DeductibleSelf-Only Enrollment: $1,500
Any One Member in a Family of Two or More: $2,800
Family of Two or More: $3,000
Calendar Year Out of Pocket Maximum
(Including Deductibles, Co-pays, and Coinsurance)
Self-Only Enrollment: $3,000
Any One Member in a Family of Two or More: $3,000
Family of Two or More: $6,000
Lifetime MaximumNone

Dependent Children Eligibility

Any Dependent Child under age 26. No age limit if disabled.

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ServiceSutter Health Plus Deductible First HDHP
Physician & Specialist$20 copay after deductible
Preventive Care Birth to Age 18No Charge, no deductible
Preventive Care Adult Routine CareNo Charge, no deductible
Preventive Care Adult Routine OB/GYNNo Charge, no deductible
Diagnostic Lab and X-Ray

Diagnostic Lab: $20 copay after deductible

Diagnostic X-ray: $10 copay per procedure after deductible

CT/PET Scans & MRI: $50 per procedure after deductible

Physical Therapy
(Medically necessary treatment only)
$20 copay after deductible
Chiropractic and AcupunctureNot covered
Mental Health & Substance Use Disorder
(Outpatient)

$20 copay MH/SUD individual after deductible
$10 copay MH/SUD group after deductible

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ServiceSutter Health Plus Deductible First HDHP
Inpatient Hospital and Physician ServicesHospitalization Facility Fee: $250 copay per day, up to 5 days after deductible
Inpatient Physician Services: No charge after deductible
Outpatient SurgeryOutpatient Surgery Fee: $20 copay per visit after deductible
MaternityDelivery and hospital inpatient services: $250 copay per day, up to 5 days after deductible
Emergency Room$100 copay after deductible
Ambulance$100 copay per trip after deductible
Mental Health & Substance Use Disorder
(Inpatient)

MH/SUD Inpatient Facility: $250 copay per day, up to 5 days after deductible

MH/SUD Inpatient Physician Services: No charge after deductible

Skilled Nursing Facility$100 copay per day up to 5 days after deductible
Up to 100 days per benefit period
Home HealthNo charge after deductible up to 100 days per year

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ServiceSutter Health Plus Deductible First HDHP
Generic or Tier 1$10 copay up to a 30 day supply after deductible
Formulary Brand or Tier 2$30 copay up to a 30 day supply after deductible
Non-Formulary Brand or Tier 3 Tier 3 - $60 copay up to a 30 day supply after deductible
Tier 4 (Specialty Drug) - 20% coinsurance ($100 per prescription maximum) up to a 30 day supply after deductible
Mail Order Benefit Generic or Tier 1$20 copay up to a 100 day supply after deductible
Mail Order Benefit Formulary Brand or Tier 2$60 copay up to a 100 day supply after deductible
Mail Order Benefit Non-Formulary Brand or Tier 3$120 copay up to a 100 day supply after deductible
Mandatory Mail OrderNo
Mandatory Generic ProgramDispense as written program

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Contact Information

Benefits Unit

Human Resources Department

Business Hours
Monday – Friday
8:00 AM – 5:00 PM
Contact us by Phone
Address
575 Administration Drive
Room 116 B
Santa Rosa, CA 95403
38.465237, -122.725363

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