Medical Plan Options & Summaries
Plans effective January 1, 2023-December 31, 2023
Summary of Employee Benefits
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.
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 | $1,750/Member $3,500/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 | $125/Procedure |
| Urgent Care | $30 Copay | $20 Copay after Ded | $25 Copay |
| Emergency Room | $150 Copay, (waived if admitted) | 20% Coinsurance after Ded | $200 Copay, (waived if admitted) |
| Lab & X-Ray | $10 Copay | $10 Copay after Ded | $10 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 | $10 Copay |
| Brand | $35 Copay | $30 Copay; Ded Waived | $30 / $60 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.
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