Medical Plan Options & Summaries

Plans effective January 1, 2022-December 31, 2022

Summary of Employee Benefits

Medical Options:

Kaiser HMOKaiser HRASutter HMOSutter DHMO
Deductible (Ind/Fam)None$2,000/$4,000None $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

DescriptionSutter Health Plus HMO $20 -$0
$1,500 OOP Max – (In Network) CA
Sutter Health Plus HMO $20 – $1000/20% (In Network) CA
Lifetime MaximumUnlimitedUnlimited
Annual DeductibleNone$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/visit20% Coinsurance after Ded
Urgent Care$20 Copay $20 Copay; Ded Waived
Emergency Room$100 Copay, waived if admitted20% Coinsurance after Ded
Lab & X-Ray$20 copay Lab/No charge x-ray
$20 Lab/$10 X-ray; Ded Waived
Durable Medical Equip20% Coinsurance20% Coinsurance after Ded
Preventive Care
AdultNo CopayNo Copay; Ded Waived
ChildrenNo CopayNo Copay; Ded Waived
Maternity Office VisitsNo CopayNo Copay; Ded Waived
Mental Health / Substance Abuse
Inpatient$250 per admission20% Coinsurance after Ded
Outpatient$20/Visit$20 Copay/Visit; Ded Waived
Chiropractic BenefitNoneNone
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
Specialty20% Coinsurance, $250 max20% Coinsurance, $100 max
Brand Name Deduct.NoneNone
NotesSee 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) 

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

DescriptionKaiser Permanente HMO CAKaiser HMO HRA (In Network) CAKaiser NW
Lifetime MaximumUnlimitedUnlimitedUnlimited
Annual DeductibleNone$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/admit20% Coinsurance after Ded$250/admit
Outpatient$250/procedure20% 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 Equip20% Coinsurance20% Coinsurance after Ded20% Coinsurance
Preventive Care
Adult/ChildrenNo CopayNo Copay No Copay
Maternity Office VisitsNo CopayNo Copay No Copay
Mental Health / Substance Abuse
Inpatient$500/admit20% Coinsurance after Ded$250/admit
Outpatient$30/Visit$20 Copay/Visit; Ded Waived$15 Copay
Chiropractic Benefit$15 Copay/30 VisitsNot CoveredNot Covered
Prescription Drug
Generic$15 Copay$10 Copay; Ded waived$15 Copay
Brand$35 Copay$30 Copay; Ded waived$30 Copay
Brand Name Deduct.NoneNone None
NotesSee 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)