Information About COVID-19 Coverage, Cost and Access to Care
Beginning Jan. 1, 2025, there are changes to coverage and cost share requirements for certain COVID-19 items and services as new members join Sutter Health Plan or existing members renew their plans. The coverage and cost share changes will only apply to members on a high-deductible health plan (HDHP).
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 Plan 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.
Members can find more information about COVID-19 vaccine appointments from the following 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 Plan Customer Service at 855-315-5800 or by TTY at 855-830-3500. Customer Service is available 8:00 am – 7:00 pm, Monday through Friday.
You can view more information on 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.
Beginning Jan. 1, 2025, there are changes to coverage and cost share requirements for certain items and services as new members join Sutter Health Plan or existing members renew their plans. The coverage and cost share changes will only apply to members on a high deductible health plan (HDHP).
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. 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. |
Sutter Health Plan does not require prior authorization for medically necessary items or services related to COVID-19.
You can call Sutter Health Plan Customer Service at 855-315-5800 or by TTY at 855-830-3500. Customer Service 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 Plan Customer Service at 855-315-5800 or by TTY at 855-830-3500. Customer Service 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-7:00 pm every day from a smartphone, tablet or computer.
General
You can view more information on the CDC website.