Sutter Health Plus
For 2017, Sutter Health Plus will be offering individual and family plans that mirror the standard benefit designs outlined by Covered California. These HMO plans, offered only by Sutter Health Plus, are not eligible for the ACA Premium Tax Credits. They will be offering the standard benefit design Platinum coinsurance, Gold coinsurance, Silver and Bronze health plans in the Sacramento Valley and Bay Area counties.
Sutter Health Plus individual and family service area map.
Sutter Health Plus is licensed in the following ZIP Codes:
- Alameda County: All ZIP Codes
- Contra Costa County: All ZIP Codes
- El Dorado County (partial): 95614, 95635, 95651, 95664, 95672, 95682, 95762
- Placer County (partial): 95602, 95603, 95648, 95650, 95658, 95661, 95663, 95677, 95678, 95681, 95703, 95713, 95722, 95746, 95747, 95765
- Sacramento County: All ZIP Codes
- San Francisco County: All ZIP Codes
- San Joaquin County: All ZIP Codes
- San Mateo County: All ZIP Codes
- Santa Clara County (partial): 94022, 94024, 94040, 94041, 94043, 94085, 94086, 94087, 94089, 94301, 94303, 94304, 94305, 94306, 95002, 95008, 95014, 95030, 95032, 95033, 95035, 95050, 95051, 95053, 95054, 95070, 95110, 95112, 95113, 95116, 95117, 95118, 95122, 95124, 95125, 95126, 95128, 95129, 95130, 95131, 95133, 95134, 95192
- Stanislaus County: All ZIP Codes
- Solano County: All ZIP Codes
- Sonoma County (partial): 94926, 94927, 94928, 94931, 94951, 94952, 94953, 94954, 94955, 94972, 94975, 94999, 95401, 95402, 95403, 95404, 95405, 95406, 95407, 95409, 95419, 95421, 95425, 95430, 95436, 95439, 95441, 95442, 95444, 95446, 95448, 95450, 95452, 95462, 95465, 95471, 95472, 95473, 95486, 95492
- Sutter County (partial): 95645, 95668, 95659
- Yolo County: All ZIP Codes
Sutter Health Plus outlined some minor changes to their health plans in their annual notice of change letter to current members.
SECTION III. 2017 EVIDENCE OF COVERAGE AND DISCLOSURE FORM CHANGES
The following explains changes and identifies updates to the benefits described in the Evidence of Coverage and Disclosure Form (EOC) for your health benefit plan.
Changes to Prior Authorization Requirements
Sutter Health Plus expanded the list on page 11 in the EOC to clarify additional covered services that require prior authorization.
Changes to Pharmacy Benefits
Sutter Health Plus revised:
- Page 47 to clarify that member cost sharing applies for preventive medications offered on the Sutter Health Plus Formulary at Tiers 2, 3 and 4 when a Tier 1 generic equivalent is available
- Page 47 to include the following examples of Preventive Medications and Supplies: Bowel preparation medications for colonoscopy screening for members of a certain age
- Pages 48 and 49 to include information on requesting brand name medications when generic medications are available. If a member or prescribing provider requests a brand name medication when a generic medication is available, the member will pay the generic copay and the difference between the pharmacy-contracted costs for the brand name and generic medication. The cost that a member pays for medications that exceeds the allowed prescription drug amount does not apply to a member’s deductible or out-of-pocket maximum. There is an exception process for a member to obtain a brand name medication at the standard brand default tier when the prescribing provider attests that it is medically necessary
- Page 70 to include information for what a member should do if the member pays the full price for a prescription
Changes to the EOC Definition Section
Sutter Health Plus added the following terms to the EOC Definition section:
- Clinically Stable
- Life-threatening
- Specialist
Changes and Clarification of EOC Language for other Benefits:
Sutter Health Plus revised:
- The Bariatric Surgery section on page 29 to clarify that if the member’s surgeon requires a specific liquid dietary product following bariatric surgery, the product will not be a covered service
- The Health Education section on page 34 to clarify the benefits covered under the health education benefit and provide information on when a member may have cost sharing for specific medically necessary services that fall under a separate benefit
- The Home Health Care section on page 36 to clarify that shift nursing or private duty nursing are excluded from coverage under the Home Health Care benefit
- Page 44 to detail covered services for preventive care or diagnostic or therapeutic purposes when medically necessary. Sutter Health Plus added the following services to the list for preventive care or diagnostic or therapeutic purposes when medically necessary: o Electrocardiograms
- Therapeutic or diagnostic injections
- Therapeutic or diagnostic radiation services
- Page 51 to remove ultraviolet light treatments from the list of Therapeutic Procedures
- The Clinical Trials section on page 57 to list travel, hospital and meals associated with participation in a clinical trial as excluded services
Physician Groups for Sutter Health Plus
- Brown and Toland Medical Group
- Mills-Peninsula Medical Group
- Palo Alto Medical Foundation
- Sutter East Bay Medical Foundation
- Sutter Pacific Medical Foundation
- Sutter Gould Medical Foundation
- Sutter Independent Physicians
- Sutter Medical Foundation
Hospitals for Sutter Health Plus
- Alta Bates Summit Medical Center (Berkeley and Oakland)
- California Pacific Medical Center (San Francisco)
- Children’s Hospital Oakland
- Dameron Hospital
- Eden Medical Center (Castro Valley)
- El Camino Hospital (Los Gatos and Mountain View)
- Menlo Park Surgical Hospital
- Memorial Medical Center, Modesto
- Mills-Peninsula Medical Center (Burlingame)
- Novato Community Hospital
- St. Joseph’s Medical Center
- Sequoia Hospital (Redwood City)
- Sutter Auburn Faith Hospital
- Sutter Delta Medical Center (Antioch)
- Sutter Medical Center, Sacramento
- Sutter Roseville Medical Center
- Sutter Santa Rosa Regional Hospital
- Sutter Solano Medical Center
- Sutter Tracy Hospital
2017 Notice of Change Letter outlining plan benefits for 2017
2017 Sutter Health Plus Individual and Family Rates
Service Area and Application
Sutter Health Plus standard benefit health plan designs.
