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 | No Copay | No Copay; Ded Waived |
| 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/Visit; 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)
- Sutter Health Plus HMO: SHP_SBC_SynodofthePacific_ML21_2022_01_v1.0
- Sutter Health Plan Benefits Coverage Matrix: SHP-BCM_SynodofthePacific_ML21_2022_01_v0.0
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 Group #602931
Kaiser NW Member Services: 1.800.813.2000 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; Ded Waived | $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% Coinsurance after Ded | 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; Ded Waived | $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)
- CA- Kaiser Traditional HMO SBC’s: Kaiser-2022 Synod of the Pacific 602931 HMO 30 SBC
- CA- Kaiser Traditional HMO Plan Principal Benefits: Kaiser-2022 Synod of the Pacific 602931 HMO 30 BS
- CA- Kaiser HRA Deductible Plan SBC’s: Kaiser-2022 Synod of the Pacific 602931 DHMO 2000 SBC
- CA- Kaiser HRA Deductible Plan Principal Benefits: Kaiser-2022 Synod of the Pacific Kaiser Princ Bene DHMO 2000 BS
- Northwest- Kaiser HMO SBC: Kaiser NW_12022_4575-003_KOM_SBC-_{595247}
- Northwest- Kaiser HMO Plan Summary: Kaiser NW_04575_003 Plan Summary
- Kaiser Chiropractic Benefits: Kaiser-2022 Synod of the Pacific 602931 Chiro BS