Forms and Resources
For convenient access, download and print the forms and resources that you need.
Member Forms and Resources
Member Forms
- Sutter Health Plus Grievance Form*
- Authorization for Use and Disclosure of Protected Health Information
- Continuity of Care Request Form and Guidelines*
- Coordination of Benefits Form
- Disabled Dependent Certification
- Individual and Family Plans Termination Form
- Member Claim Form
- Opt-Out of Covered CA Sharing
- Prescription Drug Adjustment Request
- Pharmacy Mail Order Form
- Request for Confidential Communication Form
- DMHC Grievance Form for Cancellations, Rescissions and Nonrenewals*
- 2025 Individual and Family Plan Application and Enrollment Form
- *View Additional Information About Forms
Member Resources
- 2025 Individual and Family Plan Rate Guide
- Choosing a Primary Care Physician
- Glossary of Terms
- Member Rights and Responsibilities
- Premium Payment Options
- Rights and Protections Against Surprise Medical Bills
- Right to Submit a Grievance, Rescission or Nonrenewal of Your Plan Enrollment, Subscription or Contract*
- Service Area
- Timely Access Standards
- CMS Uniform Glossary (English)
- CMS Uniform Glossary (Spanish)
- World Professional Association for Transgender Health*
- *View Additional Information About Resources
Broker Forms and Resources
2025: FOR PLANS EFFECTIVE 1/1/2025 THROUGH 12/31/2025
2024: FOR PLANS EFFECTIVE 1/1/2024 THROUGH 12/31/2024
2023: FOR PLANS EFFECTIVE 1/1/2023 THROUGH 12/31/2023
General Forms
Resources
- Premium Payment Options
- 2025 Q1 Small Group Rate Guide
- 2025 Individual and Family Plan Rate Guide
- 2025 Small Group Optional Benefit Rate Guide
- Q4 2024 Small Group Rate Guide
- Q1 2024 Small Group Rate Guide
- 2024 Individual and Family Plan Rate Guide
- 2024 Small Group Optional Benefit Rates
- Service Area
- Sutter Health Plus CSV File Template
Employer Forms and Resources
2025: FOR PLANS EFFECTIVE 1/1/2025 THROUGH 12/31/2025
2024: FOR PLANS EFFECTIVE 1/1/2024 THROUGH 12/31/2024
2023: FOR PLANS EFFECTIVE 1/1/2023 THROUGH 12/31/2023
General Forms
Employer Resources
Provider Forms and Resources
Additional Resources
Evidence of Coverage
2024 LARGE GROUP EVIDENCE OF COVERAGE (EOC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/24 THROUGH 12/31/24
2024 SMALL GROUP EVIDENCE OF COVERAGE (EOC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/24 THROUGH 12/31/24
2024 INDIVIDUAL AND FAMILY PLAN Evidence of Coverage (EOC): FOR PLANS EFFECTIVE 1/1/24 THROUGH 12/31/24
2023 LARGE GROUP EVIDENCE OF COVERAGE (EOC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
2023 SMALL GROUP EVIDENCE OF COVERAGE (EOC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
Summary of Benefits and Coverage
2025 LARGE GROUP SUMMARY OF BENEFITS AND COVERAGE (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/25 THROUGH 12/31/25
- Large Group SBC Summit ML80 HMO
- Large Group SBC Summit ML78 HMO
- Large Group SBC Summit ML84 HMO
- Large Group SBC Summit ML81 HMO
- Large Group SBC Summit ML82 HMO
- Large Group SBC Summit ML79 HMO
- Large Group SBC Summit ML83 HMO
- Large Group SBC Peak ML85 HMO
- Large Group SBC Peak ML86 HMO
- Large Group SBC Peak ML87 HMO
- Large Group SBC Peak ML88 HMO
- Large Group SBC Peak ML89 HMO
- Large Group SBC Peak ML90 HMO
- Large Group SBC Peak ML91 HMO
- Large Group SBC Ridge ML93 HMO
- Large Group SBC Ridge ML94 HMO
- Large Group SBC Ridge ML92 HMO
- Large Group SBC Vista HD40 HDHP HMO
- Large Group SBC Vista HD34 HDHP HMO
- Large Group SBC Vista HD39 HDHP HMO
- Large Group SBC Vista HD35 HDHP HMO
- Large Group SBC Vista HD37 HDHP HMO
- Large Group SBC Vista HD38 HDHP HMO
2025 SMALL GROUP SUMMARY OF BENEFITS AND COVERAGE (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/25 THROUGH 12/31/25
- Small Group SBC Platinum MS78 HMO
- Small Group SBC Platinum MS90 HMO
- Small Group SBC Gold MS87 HMO
- Small Group SBC Gold SD22 HDHP HMO
- Small Group SBC Gold MS72 HMO
- Small Group SBC Gold MS93 HMO
- Small Group SBC Silver SD21 HDHP HMO
- Small Group SBC Silver MS94 HMO
- Small Group SBC Bronze SD13 HDHP HMO
- Small Group SBC Bronze MS39 HMO
2025 INDIVIDUAL AND FAMILY PLAN SUMMARY OF BENEFITS AND COVERAGE: FOR PLANS EFFECTIVE 1/1/25 THROUGH 12/31/25
2024 LARGE GROUP SUMMARY OF BENEFITS AND COVERAGE (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/24 THROUGH 12/31/24
- 2024 Large Group SBC Summit ML80 HMO
- 2024 Large Group SBC Summit ML78 HMO
- 2024 Large Group SBC Summit ML84 HMO
- 2024 Large Group SBC Summit ML81 HMO
- 2024 Large Group SBC Summit ML82 HMO
- 2024 Large Group SBC Summit ML79 HMO
- 2024 Large Group SBC Summit ML83 HMO
- 2024 Large Group SBC Peak ML85 HMO
- 2024 Large Group SBC Peak ML86 HMO
- 2024 Large Group SBC Peak ML87 HMO
- 2024 Large Group SBC Peak ML88 HMO
- 2024 Large Group SBC CM Peak ML89 HMO
- 2024 Large Group SBC Peak ML90 HMO
- 2024 Large Group SBC Peak ML91 HMO
- 2024 Large Group SBC Ridge ML93 HMO
- 2024 Large Group SBC Ridge ML94 HMO
- 2024 Large Group SBC Ridge ML92 HMO
- 2024 Large Group SBC Vista HD33 HDHP HMO
- 2024 Large Group SBC Vista HD27 HDHP HMO
- 2024 Large Group SBC Vista HD32 HDHP HMO
- 2024 Large Group SBC Vista HD28 HDHP HMO
- 2024 Large Group SBC Vista HD30 HDHP HMO
- 2024 Large Group SBC Vista HD31 HDHP HMO
2024 SMALL GROUP SUMMARY OF BENEFITS AND COVERAGE (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/24 THROUGH 12/31/24
- 2024 Small Group SBC Platinum MS78 HMO
- 2024 Small Group SBC Platinum MS90 HMO
- 2024 Small Group SBC Gold MS87 HMO
- 2024 Small Group SBC Gold SD12 HDHP HMO
- 2024 Small Group SBC Gold MS72 HMO
- 2024 Small Group SBC Gold MS93 HMO
- 2024 Small Group SBC Silver SD11 HDHP HMO
- 2024 Small Group SBC Silver MS94 HMO
- 2024 Small Group SBC Bronze SD03 HDHP HMO
- 2024 Small Group SBC Bronze MS96 HMO
2024 INDIVIDUAL AND FAMILY PLAN SUMMARY OF BENEFITS AND COVERAGE: FOR PLANS EFFECTIVE 1/1/24
2023 LARGE GROUP SUMMARY OF BENEFITS AND COVERAGE (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
- 2023 Large Group SBC Summit ML61 HMO
- 2023 Large Group SBC Summit ML62 HMO
- 2023 Large Group SBC Summit ML63 HMO
- 2023 Large Group SBC Summit ML64 HMO
- 2023 Large Group SBC Summit ML65 HMO
- 2023 Large Group SBC Summit ML66 HMO
- 2023 Large Group SBC Summit ML67 HMO
- 2023 Large Group SBC Peak ML68 HMO
- 2023 Large Group SBC Peak ML69 HMO
- 2023 Large Group SBC Peak ML70 HMO
- 2023 Large Group SBC Peak ML71 HMO
- 2023 Large Group SBC Peak ML72 HMO
- 2023 Large Group SBC Peak ML73 HMO
- 2023 Large Group SBC Peak ML77 HMO
- 2023 Large Group SBC Ridge ML74 HMO
- 2023 Large Group SBC Ridge ML75 HMO
- 2023 Large Group SBC Ridge ML76 HMO
- 2023 Large Group SBC Vista HD20 HDHP HMO
- 2023 Large Group SBC Vista HD21 HDHP HMO
- 2023 Large Group SBC Vista HD23H DHP HMO
- 2023 Large Group SBC Vista HD24 HDHP HMO
- 2023 Large Group SBC Vista HD25 HDHP HMO
- 2023 Large Group SBC Vista HD26 HDHP HMO
2023 SMALL GROUP SUMMARY OF BENEFITS AND COVERAGE (SBC) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
- 2023 Small Group SBC Platinum MS68 HMO
- 2023 Small Group SBC Platinum MS80 HMO
- 2023 Small Group SBC Gold MS77 HMO
- 2023 Small Group SBC Gold SD02 HDHP HMO
- 2023 Small Group SBC Gold MS62 HMO
- 2023 Small Group SBC Gold MS83 HMO
- 2023 Small Group SBC Silver SD01 HDHP HMO
- 2023 Small Group SBC Silver MS84 HMO
- 2023 Small Group SBC Bronze SD48 HDHP HMO
- 2023 Small Group SBC Bronze MS86 HMO
Benefits and Coverage Matrix
2025 LARGE GROUP BENEFITS AND MATRIX (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/25 THROUGH 12/31/25
- Large Group BCM Summit ML80 HMO
- Large Group BCM Summit ML78 HMO
- Large Group BCM Summit ML84 HMO
- Large Group BCM Summit ML81 HMO
- Large Group BCM Summit ML82 HMO
- Large Group BCM Summit ML79 HMO
- Large Group BCM Summit ML83 HMO
- Large Group BCM Peak ML85 HMO
- Large Group BCM Peak ML86 HMO
- Large Group BCM Peak ML87 HMO
- Large Group BCM Peak ML88 HMO
- Large Group BCM Peak ML89 HMO
- Large Group BCM Peak ML90 HMO
- Large Group BCM Peak ML91 HMO
- Large Group BCM Ridge ML93 HMO
- Large Group BCM Ridge ML94 HMO
- Large Group BCM Ridge ML92 HMO
- Large Group BCM Vista HD40 HDHP HMO
- Large Group BCM Vista HD34 HDHP HMO
- Large Group BCM Vista HD39 HDHP HMO
- Large Group BCM Vista HD35 HDHP HMO
- Large Group BCM Vista HD37 HDHP HMO
- Large Group BCM Vista HD38 HDHP HMO
2025 SMALL GROUP BENEFITS AND COVERAGE MATRIX (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/25 THROUGH 12/31/25
- Small Group BCM Platinum MS78 HMO
- Small Group BCM Platinum MS90 HMO
- Small Group BCM Gold MS87 HMO
- Small Group BCM Gold SD22 HDHP HMO
- Small Group BCM Gold MS72 HMO
- Small Group BCM Gold MS93 HMO
- Small Group BCM Silver SD21 HDHP HMO
- Small Group BCM Silver MS94 HMO
- Small Group BCM Bronze SD13 HDHP HMO
- Small Group BCM Bronze MS39 HMO
2025 INDIVIDUAL AND FAMILY PLAN BENEFITS AND COVERAGE MATRIX (BCM): FOR PLANS EFFECTIVE 1/1/25 THROUGH 12/31/25
2024 LARGE GROUP BENEFITS AND MATRIX (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/24 THROUGH 12/31/24
- 2024 Large Group BCM Summit ML80 HMO
- 2024 Large Group BCM Summit ML78 HMO
- 2024 Large Group BCM Summit ML84 HMO
- 2024 Large Group BCM Summit ML81 HMO
- 2024 Large Group BCM Summit ML82 HMO
- 2024 Large Group BCM Summit ML79 HMO
- 2024 Large Group BCM Summit ML83 HMO
- 2024 Large Group BCM Peak ML85 HMO
- 2024 Large Group BCM Peak ML86 HMO
- 2024 Large Group BCM Peak ML87 HMO
- 2024 Large Group BCM Peak ML88 HMO
- 2024 Large Group BCM Peak ML89 HMO
- 2024 Large Group BCM Peak ML90 HMO
- 2024 Large Group BCM Peak ML91 HMO
- 2024 Large Group BCM Ridge ML93 HMO
- 2024 Large Group BCM Ridge ML94 HMO
- 2024 Large Group BCM Ridge ML92 HMO
- 2024 Large Group BCM Vista HD33 HDHP HMO
- 2024 Large Group BCM Vista HD27 HDHP HMO
- 2024 Large Group BCM Vista HD32 HDHP HMO
- 2024 Large Group BCM Vista HD28 HDHP HMO
- 2024 Large Group BCM Vista HD30 HDHP HMO
- 2024 Large Group BCM Vista HD31 HDHP HMO
2024 SMALL GROUP BENEFITS AND COVERAGE MATRIX (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/24 THROUGH 12/31/24
- 2024 Small Group BCM Platinum MS78 HMO
- 2024 Small Group BCM Platinum MS90 HMO
- 2024 Small Group BCM Gold MS87 HMO
- 2024 Small Group BCM Gold SD12 HDHP HMO
- 2024 Small Group BCM Gold MS72 HMO
- 2024 Small Group BCM Gold MS93 HMO
- 2024 Small Group BCM Silver SD11 HDHP HMO
- 2024 Small Group BCM Silver MS94 HMO
- 2024 Small Group BCM Bronze SD03 HDHP HMO
- 2024 Small Group BCM Bronze MS96 HMO
2024 INDIVIDUAL AND FAMILY PLAN BENEFITS AND COVERAGE MATRIX (BCM): FOR PLANS EFFECTIVE 1/1/24 THROUGH 12/31/24
2023 LARGE GROUP BENEFITS AND COVERAGE MATRIX (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
- 2023 Large Group BCM Summit ML61 HMO
- 2023 Large Group BCM Summit ML62 HMO
- 2023 Large Group BCM Summit ML63 HMO
- 2023 Large Group BCM Summit ML64 HMO
- 2023 Large Group BCM Summit ML65 HMO
- 2023 Large Group BCM Summit ML66 HMO
- 2023 Large Group BCM Summit ML67 HMO
- 2023 Large Group BCM Peak ML68 HMO
- 2023 Large Group BCM Peak ML69 HMO
- 2023 Large Group BCM Peak ML70 HMO
- 2023 Large Group BCM Peak ML71 HMO
- 2023 Large Group BCM Peak ML72 HMO
- 2023 Large Group BCM Peak ML73 HMO
- 2023 Large Group BCM Peak ML77 HMO
- 2023 Large Group BCM Ridge ML74 HMO
- 2023 Large Group BCM Ridge ML75HMO
- 2023 Large Group BCM Ridge ML76 HMO
- 2023 Large Group BCM Vista HD20 HDHP HMO
- 2023 Large Group BCM Vista HD21 HDHP HMO
- 2023 Large Group BCM Vista HD22 HDHP HMO
- 2023 Large Group BCM Vista HD23 HDHP HMO
- 2023 Large Group BCM Vista HD24 HDHP HMO
- 2023 Large Group BCM Vista HD25 HDHP HMO
- 2023 Large Group BCM Vista HD26 HDHP HMO
2023 SMALL GROUP BENEFITS AND COVERAGE MATRIX (BCM) HMO PLANS: FOR PLANS EFFECTIVE 1/1/23 THROUGH 12/31/23
- 2023 Small Group BCM Platinum MS68 HMO
- 2023 Small Group BCM Platinum MS80 HMO
- 2023 Small Group BCM Gold MS77 HMO
- 2023 Small Group BCM Gold SD02 HDHP HMO
- 2023 Small Group BCM Gold MS62 HMO
- 2023 Small Group BCM Gold MS83 HMO
- 2023 Small Group BCM Silver SD01 HDHP HMO
- 2023 Small Group BCM Silver MS84 HMO
- 2023 Small Group BCM Bronze SD48 HDHP HMO
- 2023 Small Group BCM Bronze MS86 HMO
Sutter Health Plus Product Portfolio
2025 Product Portfolio
2024 Product Portfolio
2023 Product Portfolio