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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.
Benefit Charts
Employees and Retirees
Medical Plan Summary
Office Visits and Professional Services
Surgical and Hospital Services
Prescription Drugs
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 Hospital Services DHMO |
|---|---|
| Calendar Year Deductible | $1,000 Self-Only Enrollment
|
| Calendar Year Out of Pocket Maximum
(Including Deductibles, Co-pays, and Coinsurance) | $3,000 Self-Only Enrollment
|
| Lifetime Maximum | None |
| Dependent Children Eligibility | Any Dependent child under age 26 Disabled: No age limit |
Office Visit and Professional Services
| Service | Sutter Health Plus Hospital Services DHMO |
|---|---|
| Physician & Specialist Office Visits | $20 copay, no deductible |
| Preventive Care Adult Routine Care | No Charge, no deductible |
| Preventive Care Adult Routine Care OB/GYN | No Charge, no deductible |
| Diagnostic Imaging, Lab, and X-Ray | Diagnostic 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 Acupuncture | Chiropractic: $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 |
Surgical and Hospital Services
| Service | Sutter Health Plus Hospital Services DHMO |
|---|---|
| Inpatient Hospital and Physician Services | 20% Coinsurance after deductible |
| Outpatient Surgery | 20% Coinsurance after deductible |
| Maternity | 20% Coinsurance after deductible |
| Emergency Room | 20% Coinsurance after deductible |
| Ambulance | $150 per trip, no deductible |
| Mental Health & Substance Use Disorder (Inpatient) | 20% Coinsurance after deductible |
| Skilled Nursing Facility | 20% Coinsurance, no deductible
Up to 100 days per benefit |
| Home Health | No Charge (deductible doesn't apply)
100 visits per year |
Prescription Drugs
| Service | Sutter 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 3 | Tier 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 Order | No |
| Mandatory Generic Program | Dispense as written program |