Medical Plan Options & Summaries

Plans effective January 1, 2022-December 31, 2022

SUMMARY OF EMPLOYEE BENEFITS

 

Medical Options:

 

Kaiser HMO

Kaiser HRA

Sutter HMO

Sutter DHMO

Deductible (Ind. /Fam.)

None

$2,000/$4,000

None

$1,000/$2,000

Out Of Pocket Max

$1,500/$3,000

$4,000/$8,000

$1,500/$3,000

$3,000/$6,000

Office Visit

$30

$20 after ded.

$20

$20 (ded. waived)

Prescription

$15/$35/30%

$10/$30/20%

$10/$30/$60/20%

$10/$30/$60/20%



Sutter Health Plus Plan Options

The Synod of the Pacific offers a choice of two medical plans in California with Sutter Health Plus. Find out if Sutter services your Church/Org by entering your zip code at www.sutterhealthplus.org/providersearch. Note: Sutter has the “live/work rule” where employees living or working within 30 miles of a Sutter service area are eligible for their plans.


Sutter Health Plus Member Services:  1.855.315.5800                                   Group # 190002

 

Description

Sutter Health Plus HMO $20 - $0

$1,500 OOP Max- (In Network) CA

Sutter Health Plus HMO $20 -

$1000/20% (In Network) CA

Lifetime Maximum

Unlimited

Unlimited

Annual Deductible

None

$1,000/Member;   $2,000/Family

Annual Out-of-Pocket Maximum

$1,500/Member

$3,000/Family

$3,000/Member

$6,000/Family

Professional

 

 

·       Physician Visit

$20 Copay

$20 Copay; Ded Waived

·       Specialist

$20 Copay

$20 Copay; Ded Waived

Hospital Services

 

 

·       Inpatient

$250 per admission

20% Coinsurance after Ded

·       Outpatient

$100/visit

20% Coinsurance after Ded

·       Urgent Care

$20 Copay

$20 Copay; Ded Waived

·       Emergency Room

$100 Copay,

(waived if admitted)

20% Coinsurance after Ded

Lab & X-Ray

$20 copay Lab / No charge X-Ray

$20 Lab/$10 X-Ray; Ded Waived

Durable Medical Equip

20% Coinsurance

20% Coinsurance, after Ded.

Preventive Care

 

 

·       Adult/Children

No Copay

No Copay; Ded Waived

Maternity Office Visits

No Copay

No Copay; Ded Waived

Mental Health / Substance

Abuse

 

 

·       Inpatient

$250 per admission

$20% Coinsurance after Ded

·       Outpatient

$20/Visit

$20 Copay Ded. Waived

Chiropractic Benefit

None

None

Prescription Drug

 

 

·       Generic

$10 Copay

$10 Copay; Ded Waived

·       Brand

$30 Copay

$30 Copay; Ded Waived

·       Brand Non-Formulary

$60 Copay

$60 Copay; Ded Waived

·       Specialty

20% Coinsurance, $250 max

20% Coinsurance, $100 max

·       Brand Name Deduct.

None

None

·                Notes

See Plan for more details

See Plan for more details

 IMPORTANT NOTE: This information is intended as a summary only; benefits may contain limitations and exclusions. Benefits cannot be guaranteed in advance and are subject to change by the insurer without notice. If a conflict exists between this summary and the policy, the policy will be controlling.

Summary of Benefits and Coverages (SBC's) (Please click on the links below to view the SBC's)


Kaiser Medical Plan Options

The Synod of the Pacific offers a choice of two medical plans in California with Kaiser and one medical plan with Kaiser in Oregon and Washington (NW).


Kaiser CA Member Services:  1.800.464.4000        Kaiser NW Member Services: 1.800.813.2000

Group #602931                                               Group # 04575

 

Description

Kaiser Permanente HMO

CA

Kaiser HMO

HRA (In Network) CA

Kaiser NW

Lifetime Maximum

Unlimited

Unlimited

Unlimited

Annual Deductible

None

$2,000/Member;   $4,000/Family

None

HRA Allocation (first monies used toward medical expenses)

n/a

$1,000/Member; $2,000/Family

(allocated by Synod on 1/1/20 for the plan year)

n/a

Annual Out-of-Pocket

Maximum

$1,500/Member

$3,000/Family

$4,000/Member

$8,000/Family

$2,000/Member

$4,000/Family

Professional

 

 

 

·       Physician Visit

$30 Copay

$20 Copay after Ded

$15 Copay

·       Specialist

$30 Copay

$20 Copay after Ded

$25 Copay

·       Physical Therapy

$30 Copay

$20 Copay after Ded

$15 Copay/20 Visits

Hospital Services

 

 

 

·       Inpatient

$500/admit

20% Coinsurance after Ded

$250/admit

·       Outpatient

$250/Procedure

20% Coinsurance after Ded

$100/Procedure

·       Urgent Care

$30 Copay

$20 Copay after Ded

$25 Copay

·       Emergency Room

$150 Copay,

(waived if admitted)

20% Coinsurance after Ded

$150 Copay,

(waived if admitted)

Lab & X-Ray

$10 Copay

$10 Copay after Ded

$15 Copay

Durable Medical Equip

20% Coinsurance

20% Coins.; Ded Waived

20% Coinsurance

Preventive Care

 

 

 

·       Adult/Children

No Copay

No Copay

No Copay

Maternity Office Visits

No Copay

No Copay

No Copay

Mental Health /

Substance Abuse

 

 

 

·       Inpatient

$500/admit

20% Coinsurance after Ded

$250/admit

·       Outpatient

$30/Visit

$20 Copay/Visit after Ded

$15 Copay

Chiropractic Benefit

$15 Copay/30 Visits

Not Covered

Not Covered

Prescription Drug

 

 

 

·       Generic

$15 Copay

$10 Copay; Ded Waived

$15 Copay

·       Brand

$35 Copay

$30 Copay; Ded Waived

$30 Copay

·       Brand Name

Deduct.

None

None

None

·       Notes

See Plan for more details

See Plan for more details

See Plan for more details

 IMPORTANT NOTE: This information is intended as a summary only; benefits may contain limitations and exclusions. Benefits cannot be guaranteed in advance and are subject to change by the insurer without notice. If a conflict exists between this summary and the policy, the policy will be controlling.

Summary of Benefits and Coverages (SBC's) (Please click on the links below to view the SBC's)