Human Resources Benefits Unit

Sutter Health Plus Hospital Services DHMO

Hospital Services DHMO ML21 $20 copay plan for primary care, specialist or chiropractic visits. Chiropractic visits are limited to 20 visits per year. Prescription medications are available through retail or mail order at a copay range of $10 - $120. Tier 4 prescription medications are covered at a 20% coinsurance, not to exceed $100 per prescription.

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.

Plan Information Sutter Health Plus Hospital Services DHMO
Calendar Year Deductible

$1,000 Self-Only Enrollment
$1,000 Any one member in a family of two or more
$2,000 Family of two or more

Calendar Year Out of Pocket Maximum
(Including Deductibles, Co-pays, and Coinsurance)

$3,000 Self-Only Enrollment
$3,000 Any one member in a family of two or more
$6,000 Family of two or more

Lifetime MaximumNone
Dependent Children Eligibility

Any Dependent child under age 26

Disabled: No age limit

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ServiceSutter Health Plus Hospital Services DHMO
Physician & Specialist Office Visits$20 copay, no deductible
Preventive Care Adult Routine CareNo Charge, no deductible
Preventive Care Adult Routine Care OB/GYNNo Charge, no deductible
Diagnostic Imaging, Lab, and X-RayDiagnostic Lab: $20 copay, no deductible Diagnostic X-ray: $10 copay per procedure, no
deductible CT/PET Scans & MRI: $50 per procedure, no deductible
Physical Therapy (Medically necessary treatment only)$20 co-pay, no deductible
Chiropractic and AcupunctureChiropractic: $20 Copay, no deductible up to 20 visits per year
Acupuncture: Not covered
Mental Health & Substance Use Disorder
(Outpatient)
Individual Therapy: $20 copay, no deductible
Group Therapy: $10 copay, no deductible

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ServiceSutter Health Plus Hospital Services DHMO
Inpatient Hospital and Physician Services20% Coinsurance after deductible
Outpatient Surgery20% Coinsurance after deductible
Maternity20% Coinsurance after deductible
Emergency Room20% Coinsurance after deductible
Ambulance$150 per trip, no deductible
Mental Health & Substance Use Disorder (Inpatient)20% Coinsurance after deductible
Skilled Nursing Facility20% Coinsurance, no deductible
Up to 100 days per benefit
Home HealthNo Charge (deductible doesn't apply)
100 visits per year

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ServiceSutter Health Plus Hospital Services DHMO
Generic or Tier 1$10 copay up to a 30 day supply, no deductible
Formulary Brand or Tier 2$30 copay up to a 30 day supply, no deductible
Non-Formulary Brand or Tier 3Tier 3 - $60 copay up to a 30 day supply, no deductible
Tier 4 (Specialty Drug) - 20% coinsurance up to a maximum of $100 per prescription up to a 30 day supply, no deductible
Mail Order Benefit Generic or Tier 1$20 copay up to a 100 day supply, no deductible
Mail Order Benefit Formulary Brand or Tier 2$40 copay up to a 100 day supply, no deductible
Mail Order Benefit Non-Formulary Brand or Tier 3$120 copay up to a 100 day supply, no 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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