| 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. For HDHPs only: For new members or members renewing on or after Jan. 1, 2025, COVID-19 diagnostic and screening tests are covered at no cost share after the annual plan deductible has been met. | 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. | The standard urgent care or emergency services cost share applies based on place of service. |
Over-the-counter (OTC) tests –
No prescription | We 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. For HDHPs only: For new members or members renewing on or after Jan. 1, 2025, Sutter Health Plan will reimburse the cost of the OTC tests after the annual deductible has been met. | Members must submit a completed Member Claim Form to be reimbursed up to $12 per test. For HDHPs only: For new members or members renewing on or after Jan. 1, 2025, Sutter Health Plan will reimburse the cost of the OTC tests after the annual deductible has been met. |
OTC tests –
With prescription | We 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® . For HDHPs only: For new members or members renewing on or after Jan. 1, 2025, COVID-19 OTC tests are covered at no cost share after the annual plan deductible has been met. | No cost share when obtained at a pharmacy and processed through the outpatient pharmacy benefit with CVS Caremark®. For HDHPs only: For new members or members renewing on or after Jan. 1, 2025, COVID-19 OTC tests are covered at no cost share after the annual plan deductible has been met. |
| 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. For HDHPs only: For new members or members renewing on or after Jan. 1, 2025, COVID-19 therapeutics are covered at no cost share after the annual plan deductible has been met. | No cost share. For HDHPs only: For new members or members renewing on or after Jan. 1, 2025, COVID-19 therapeutics are covered at no cost share after the annual plan deductible has been met. |
