Page 8 - 2021 Sample Benefit Booklet

MEDICAL COVERAGE

Sutter Health Plus

ABC Group offers three comprehensive health plans, a Bronze and a Gold plan, through Kaiser Per- manente,
and a Bronze plan through Sutter Health Plus. ABC Group will contribute 100% of the em- ployee cost
towards the Bronze plans through Kaiser or Sutter Health Plus. Employees are responsible for paying the cost
of their dependents. We will fund up to $4,000 of your out of pocket expenses incurred under the Kaiser or
Sutter Health Plus Bronze plans for employees. Another $1,000 will be added for those covering dependents
($5,000 total). The funding for these out of pocket expenses will be provided through a Visa debit card
administered by Administrative Solutions Inc (ASi). Please refer to the Bronze benefit summaries for more
details.

Sutter Heath Plus SD28 HMO (BasePlan)

Plan Features Bronze 60 HSA HMO SD28 ABC Group Funding

Annualdeductible $6,900 per individual/$13,800 per family $2,000 per individual/$4,000 perfamily

Annual Out‐of‐Pocket maximum $6,900 per individual/$13,800 per family $2,000 per individual/$4,000 perfamily

Lifetimemaximum Unlimited
Medical Benefits What you pay

Doctor’s Office Visits After $2,000 individual/$4,000 family BB Funds
0% after $4,900 individual/$9,800 family maximum
After $2,000 individual/$4,000 family BB Funds
Specialists Office Visits
0% after $4,900 individual/$9,800 family maximum

Preventive Care
(includes x‐ray &lab) Covered at 100%

X‐Ray and LaboratoryServices After $2,000 individual/$4,000 family BB Funds
0% after $4,900 individual/$9,800 family maximum

Prescription DrugBenefits

Retail (30‐day supply) After $2,000 individual/$4,000 family BB Funds
Generic & FormularyBrands 0% after $4,900 individual/$9,800 family maximum

HospitalBenefits
After $2,000 individual/$4,000 family BB Funds
InpatientHospitalization 0% after $4,900 individual/$9,800 family maximum

Mental Health/Substance Abuse

After $2,000 individual/$4,000 family BB Funds
Inpatient/Outpatient Services 0% after $4,900 individual/$9,800 family maximum

After $2,000 individual/$4,000 family BB Funds
Emergency Room Copay 0% after $4,900 individual/$9,800 family maximum

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