Information About COVID-19 Coverage, Cost and Access to Care
Coverage and cost share for certain COVID-19 services performed by out-of-network providers will be changing as the requirements put in place during the public health emergency come to an end. As a courtesy to our members, Sutter Health Plus will continue to waive cost share for those services through Dec. 31, 2023.
Beginning Jan. 1, 2024, we will implement changes to coverage and cost share requirements for certain items and services as new members join Sutter Health Plus or existing members renew their plans. The coverage and cost share changes will only apply to some items and services obtained from out-of-network providers or vendors.
Frequently Asked Questions
We understand that you may have more questions about vaccines, coverage, cost and access to care due to COVID-19.
The FAQs below are provided to help answer some of your questions.
Vaccines
Yes. Sutter Health Plus covers COVID-19 vaccines administered by in-network and out-of-network providers, in accordance with state requirements.
The Centers for Disease Control and Prevention (CDC) vaccine recommendations vary based on age, medical condition and vaccine type. The CDC website provides detailed information about how to tell if you are up to date with your vaccine, including any necessary booster shots or additional primary doses.
You can find additional information on COVID-19 vaccines on the Sutter Health COVID-19 Vaccine Resources page.
Members can find more information about COVID-19 vaccine appointments from the following resources:
- The Sutter Health COVID-19 Vaccine Resources
- Your local pharmacy
- The My Turn website hosted by the California Department of Public Health.
There is no member cost share for COVID-19 vaccines. This includes any vaccines requiring more than one injection.
You can call Sutter Health Plus Member Services at (855) 315-5800 or by TTY at (855) 830-3500. Member Services is available 8:00 am – 7:00 pm, Monday through Friday.
You can view more information in the Sutter Health COVID-19 Vaccine Resources or the CDC website.
Coverage and Cost
Coverage and cost share requirements for items and services related to COVID-19 depend on the item or service. As a courtesy to our members, Sutter Health Plus will continue to waive cost share for certain services through Dec. 31, 2023.
Beginning Jan. 1, 2024, we will implement changes to coverage and cost share requirements for certain items and services as new members join Sutter Health Plus or existing members renew their plans. The coverage and cost share changes will only apply to some items and services obtained from out-of-network providers or vendors.
Refer to the following table for more information.
COVID-19 Item or Service Coverage Requirements and Limitations In-Network Out-of-Network Vaccines We cover COVID-19 vaccines administered by in-network and out-of-network providers, in accordance with state and federal requirements. No cost share. No cost share. Screening and Testing We cover COVID-19 screening when ordered by a treating provider as part of an individual medical assessment. Coverage includes any screening-related services, such as visits to a primary care physician (PCP), urgent care or emergency department, as well as lab tests. No cost share. No cost share through Dec. 31, 2023.
For our new members, or members renewing on or after Jan. 1, 2024, the standard benefit cost share applies based on place of service.
Treatment for confirmed COVID-19 diagnosis We cover COVID-19 treatment when ordered by a treating provider as part of an individual medical assessment. Coverage includes any treatment- related services, such as visits to a PCP, urgent care and emergency department, as well as lab tests.
Beginning Jan. 1, 2024, we only cover out-of-network treatment related to a confirmed diagnosis of COVID-19 treatment when services are provided as part of urgent care or emergency care.
Standard benefit cost share applies based on place of service. Standard benefit cost share applies based on place of service through Dec. 31, 2023.
For our new members, or members renewing on or after Jan. 1, 2024, the standard urgent care or emergency services cost share applies based on place of service.
Over-the-counter (OTC) tests –
No prescriptionWe limit coverage to eight OTC tests per member, per month. No individual medical assessment is required for coverage.
Members are responsible for the full cost of additional OTC tests exceeding this limit.
Members must submit a completed Member Claim Form to be reimbursed the amount they paid for the tests. Members must submit a completed Member Claim Form to be reimbursed the amount they paid for the tests.
No change to reimbursement amounts through Dec. 31, 2023.
New members, or members renewing on or after Jan. 1, 2024, must submit a completed Member Claim Form to be reimbursed up to $12 per test.
OTC tests –
With prescriptionWe do not limit coverage for OTC tests when prescribed by a treating provider as part of an individual medical assessment. No cost share when obtained at a pharmacy and processed through the outpatient pharmacy benefit with CVS Caremark® . No cost share when obtained at a pharmacy and processed through the outpatient pharmacy benefit with CVS Caremark®. Prescription drugs and other therapeutics We cover COVID-19 prescription drugs and other therapeutics when ordered by a treating provider as part of an individual medical assessment. No cost share. No cost share. Sutter Health Plus does not require prior authorization for medically necessary items or services related to COVID-19.
You can call Sutter Health Plus Member Services at (855) 315-5800 or by TTY at (855) 830-3500. Member Services is available 8:00 am – 7:00 pm, Monday through Friday.
Access
We recommend contacting your PCP to ask if COVID-19 screening or testing is needed based on your personal circumstances. If your PCP recommends COVID-19 screening or testing, they will be able to help direct you to a location that can provide you services. Working with your PCP to get testing at an in-network location helps your doctor manage your care more effectively.
If you need more help, you can call Sutter Health Plus Member Services at (855) 315-5800 or by TTY at (855) 830-3500. Member Services is available 8:00 am – 7:00 pm, Monday through Friday.
You can purchase at-home OTC COVID-19 tests from local retail pharmacies; retail stores such as Target, Walmart or Costco; grocery stores; and online vendors. You do not need a prescription or clinical assessment by a provider. The tests must be authorized for use by the FDA.
You should call your PCP or our 24-Hour Nurse Advice Line for help with clinical questions. You can call the 24-Hour Nurse Advice Line at (855) 836-3500.
You also have access to video visits with licensed providers for treatment and advice. Video visits are available 11:00 am to 7:00 pm every day from a smartphone, tablet or computer.
General
You can view more information in the Sutter Health COVID-19 Resources. You can also get additional information on the CDC website.