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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.
Benefit Charts
For Employees and Retirees
Office and Professional Services
Premium Rates
For Employees
Employee Semi Monthly Medical Plan Premiums
Extra-Help Semi Monthly Medical Plan Premiums
For Retirees
Medical Plan Summary
| Plan Information | Sutter Health Plus Deductible First HDHP |
|---|---|
| Calendar Year Deductible | Self-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 Maximum | None |
Dependent Children Eligibility | Any Dependent Child under age 26. No age limit if disabled. |
Office Visits and Professional Services
| Service | Sutter Health Plus Deductible First HDHP |
|---|---|
| Physician & Specialist | $20 copay after deductible |
| Preventive Care Birth to Age 18 | No Charge, no deductible |
| Preventive Care Adult Routine Care | No Charge, no deductible |
| Preventive Care Adult Routine OB/GYN | No 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 Acupuncture | Not covered |
| Mental Health & Substance Use Disorder
(Outpatient) | $20 copay MH/SUD individual after deductible |
Surgical and Hospital Services
| Service | Sutter Health Plus Deductible First HDHP |
|---|---|
| Inpatient Hospital and Physician Services | Hospitalization Facility Fee: $250 copay per day, up to 5 days after deductible Inpatient Physician Services: No charge after deductible |
| Outpatient Surgery | Outpatient Surgery Fee: $20 copay per visit after deductible |
| Maternity | Delivery 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 Health | No charge after deductible up to 100 days per year |
Prescription Drugs
| Service | Sutter 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 Order | No |
| Mandatory Generic Program | Dispense as written program |