Information About COVID-19 Coverage, Cost and Access to Care
Sutter Health Plus covers COVID-19 vaccines and COVID-19 screening and testing at no cost to members according to state and federal guidelines. This includes over-the-counter (OTC) COVID-19 tests that are authorized for use by the Food and Drug Administration (FDA).
Frequently Asked Questions
We understand that you may have more questions about coverage, cost and access to care due to COVID-19. The below FAQs are provided to help answer some of your questions.
Vaccines FAQs
Yes. Sutter Health Plus covers COVID-19 vaccines in accordance with the requirements established by the Coronavirus Aid, Relief, and Economic Security (CARES) Act. This includes any vaccines administered over more than one injection.
Yes. If you are currently eligible to get a COVID-19 vaccine, Sutter Health Plus will cover it even if you get it from an out-of-network provider. This coverage is in accordance with the requirements established by the CARES Act.
As of June 19, 2022, all individuals in California six months and older are eligible to get COVID-19 vaccines.
COVID-19 Vaccine Eligibility
Recommended Ages Pfizer Moderna Janssen/J&J Age 6 months through 4 years Yes – a primary series of three injections Yes – a primary series of two injections No Ages 5 through 17 Yes – a primary series of two injections Yes – a primary series of two injections No Age 18 and older Yes – a primary series of two injections Yes – a primary series of two injections Yes – a single injection You can find more COVID-19 vaccine information in the Sutter Health COVID-19 FAQs. You can also get additional information on the CDC website.
The current CDC recommendations for COVID-19 vaccine booster shots vary based on age, medical condition and vaccine type. Please review the following grid for more information.
COVID-19 Booster Shot Recommendations
Recommended Ages Pfizer Moderna Janssen/J&J Age 4 and under No No No Ages 5 to 11 First Booster Shot:
Yes (only Pfizer)
five months after completion of primary vaccine seriesSecond Booster Shot:
NoNo No Ages 12 to 17 First Booster Shot:
Yes (only Pfizer)
five months after completion of primary vaccine seriesSecond Booster Shot:
Yes (only Pfizer) for certain individuals with compromised immune systems four months after the first Pfizer booster shot
No No Ages 18 to 49 First Booster Shot:
Yes (mix and match) five months after completion of primary vaccine series
Second Booster Shot:
Yes (mix and match) for certain individuals with compromised immune systems four months after the first booster shot of any of the three previously approved COVID-19 vaccines
Also available to individuals who had the Janssen/J&J first booster shot.
First Booster Shot:
Yes (mix and match) five months after completion of primary vaccine series
Second Booster Shot:
Yes (mix and match) for certain individuals with compromised immune systems four months after the first booster shot of any of the three previously approved COVID-19 vaccines
Also available to individuals who had the Janssen/J&J first booster shot.
First Booster Shot:
Yes (mix and match) two months after completion of primary vaccine
Second Booster Shot:
No
Age 50 and older First Booster Shot:
Yes (mix and match) five months after completion of primary vaccine series
Second Booster Shot:
Yes (mix and match) four months after the first booster shot of any of the three previously approved COVID-19 vaccines
First Booster Shot:
Yes (mix and match) five months after completion of primary vaccine series
Second Booster Shot:
Yes (mix and match) four months after the first booster shot of any of the three previously approved COVID-19 vaccines
First Booster Shot:
Yes (mix and match) two months after completion of primary vaccine
Second Booster Shot:
No
You can contact your primary care physician (PCP) if you have questions about COVID-19 booster shots. Your provider is still not able to schedule COVID-19 vaccines. See below for vaccine appointment resources.
You can also find more information on COVID-19 vaccine booster shots in the Sutter Health COVID-19 Vaccine Resources or on the CDC website.
The CDC currently recommends that certain individuals with moderately to severely compromised immune systems should get an additional primary shot of the COVID-19 vaccine. The CDC recommendation varies based on age and the vaccine type. Please review the following grid for more information.
COVID-19 Additional Primary Dose Recommendations
Recommended Ages Pfizer Moderna Janssen/J&J Age 5 months and under No No No Ages 6 months through 4 years No – the primary series already includes a third shot Yes – four weeks after the second shot No Age 5 and older Yes – four weeks after the second shot Yes – four weeks after the second shot No You can contact your PCP to see if they recommend an additional dose for you. Your provider is still not able to schedule COVID-19 vaccines. See the question below for vaccine appointment resources.
You can also find more information on additional COVID-19 vaccine doses in the Sutter Health COVID-19 Vaccine Resources or on the CDC website.
Sutter Health Plus wants to remind our members that COVID-19 vaccine appointments are based on availability. The following resources may provide information about COVID-19 vaccine appointments:
- The Sutter Health COVID-19 Vaccine Resources
- Your local pharmacy
- The California COVID-19 website
- The California My Turn website
There is no member cost share for COVID-19 vaccines. This includes any vaccines administered over more than one injection. This cost share waiver is for the length of the public health emergency in accordance with state and federal regulations.
You can call Sutter Health Plus Member Services at (855) 315-5800. Member Services is available 8:00 am – 7:00 pm, Monday through Friday.
Yes, you can get a COVID-19 vaccine at home if you are getting home health services or otherwise homebound. You can schedule an in-home COVID-19 vaccine by:
- Visiting the California My Turn website and selecting the option for an in-home vaccine
- Calling the California COVID-19 Hotline at (833) 422-4255 and requesting an in-home vaccine
Yes, you can get help with transportation to a COVID-19 vaccination location if you are getting home health services, or are otherwise homebound, and do not want an in-home vaccine. You can request transportation to a COVID-19 vaccination location by:
- Visiting the California My Turn website and registering your need for transportation
- Calling the California COVID-19 Hotline at (833) 422-4255 and requesting an in-home vaccine
You can view more information in the Sutter Health FAQs. You can also get additional information on the CDPH website or the CDC website.
Coverage FAQs
Sutter Health Plus covers COVID-19 screening in accordance with state and federal regulations. We encourage you to contact your PCP to see if they recommend screening for you at this time.
Sutter Health Plus covers COVID-19 testing in accordance with state and federal regulations. This includes OTC COVID-19 tests that are authorized for use by the FDA. You can buy OTC COVID-19 tests at retail pharmacies, grocery stores and online without a prescription or other clinical assessment by a provider. We encourage you to contact your PCP to see if they recommend testing for you at this time.
Sutter Health Plus covers medically necessary treatment related to a diagnosis of COVID-19.
Sutter Health Plus does not require prior authorization at this time for services related to medically necessary COVID-19 screening, testing, or treatment.
We consider services medically necessary if you experience symptoms and meet CDC criteria for screening, testing, or treatment. We also defer to the clinical judgement of the treating provider to determine medical necessity.
Sutter Health Plus covers out-of-area urgent and emergent services for our members. Services related to COVID-19 are considered urgent at this time.
Sutter Health Plus covers telehealth visits. We encourage members to schedule video or telephonic visits for your convenience. You can access telehealth services by using:
- 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.
- The Sutter Health Plus 24-Hour Nurse Advice line at (855) 836-3500.
You can also contact your PCP directly to discuss symptoms and additional telehealth options that might be available through their medical group.
Sutter Health Plus covers telehealth services offered by our plan partner, U.S. Behavioral Health Plan, California (USBHPC), for the treatment of mental health, behavioral health and substance use disorders. You can call USBHPC at (855) 202-0984 or go to their website to find a provider or set up an appointment.
Cost FAQs
There is no member cost share for COVID-19 screening when done by a treating provider as part of an individual medical assessment in accordance with state and federal regulations.
There is no member cost share for COVID-19 testing in accordance with state and federal regulations when done by a treating provider as part of an individual medical assessment in accordance with state and federal regulations.
Sutter Health Plus limits coverage of OTC COVID-19 tests bought without a prescription or clinical assessment by a provider to eight tests per member, per one-month period. Members are responsible for the full cost of OTC tests that exceed this limit.
This cost share waiver is for the length of the public health emergency in accordance with state and federal regulations. There is currently no end date because the public health emergency is ongoing.
You must submit a Member Claim Form to request reimbursement for COVID-19 tests you bought at a retail pharmacy, grocery store or online without a prescription or other clinical assessment by a provider. You must use a separate Claim Form for each member you are requesting reimbursement for. The form is also available on the member portal at shplus.org/memberportal (registration required).
Common services related to medically necessary COVID-19 screening and testing include, but are not limited to, primary care provider (PCP) office visits, urgent care visits, emergency department visits, telehealth visits, and lab tests.
Standard member cost shares apply for COVID-19 related treatment.
Standard member cost shares apply to outpatient prescription drugs related to COVID-19.
You can call Sutter Health Plus Member Services at (855) 315-5800. Member Services is available 8:00 am to 7:00 pm, Monday through Friday.
Access FAQs
Sutter Health Plus wants to remind our members that COVID-19 screening and testing appointments are based on availability. Sutter Health Plus suggests that you contact your PCP to see if they recommend screening or testing at this time. If your PCP recommends COVID-19 screening or testing, they will be able to help direct you to an in-network COVID-19 testing location.
If you are not able to get in-network COVID-19 testing, the following resources may provide information about COVID-19 screening and testing appointment options:
- The Sutter Health COVID-19 Testing FAQs website
- Your local pharmacy
- The California COVID-19 website
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. Member Services is available 8 a.m. to 7 p.m., Monday through Friday.
You can purchase at-home OTC COVID-19 tests from retail pharmacies; some retail stores, including but not limited to, Target, Walmart or Costco; grocery stores; or online vendors without a prescription or other clinical assessment by a provider. The tests must be authorized for use by the FDA.
You can also sign up to get four free at-home OTC COVID-19 tests per household from the federal government.
You can access telehealth services by using:
- 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.
- The Sutter Health Plus 24-Hour Nurse Advice line at (855) 836-3500.
You can also contact your PCP directly to discuss symptoms and additional telehealth options that might be available through their medical group.
You can call USBHPC at (855) 202-0984 or go to their website to find a provider or set up an appointment.
USBHPC offers resources to help manage increased stress and anxiety due to COVID-19 on their website. You can also call USBHPC’s toll-free COVID-19 help line at (866) 342-6892.
You can call Sutter Health Plus Member Services at (855) 315-5800. Member Services is available 8:00 am – 7:00 pm, Monday through Friday.
You should call your PCP or the Sutter Health Plus 24-Hour Nurse Advice Line for help with clinical questions. You can call Sutter Health Plus 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 convenient and ease pressure on provider offices, emergency rooms, and urgent care centers. Video visits are available 11:00 am – 7:00 pm every day from a smartphone, tablet or computer.
General FAQs
You can view more information in the Sutter Health COVID-19 FAQs. You can also get additional information on the CDC website.