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COVID-19 Coverage for CalPERS Health Plan Members

The federal public health emergency for COVID-19 ended on May 11, 2023. CalPERS member costs, coverage, and access for testing and treatment may change depending on whether you are in a CalPERS Basic or Medicare plan, in an HMO, EPO, or PPO plan, or seeking services inside or outside California.

Note: All CalPERS members should consult with their health plans and providers to understand how the end of the federal public health emergency affects their particular benefit options.

Basic Plan Members

For Basic plan members, California law adds six months to the end of federal COVID-19 public health emergency requirements, so those residing in California are entitled to continuing coverage for COVID-19 diagnostic tests, vaccines, and treatment (in- or out-of-network) with no prior authorization or cost to members until November 11, 2023.

After November 11, 2023, access to COVID-19-related services will continue but cost-sharing may apply. Cost sharing is the share of health insurance costs that you pay out of your own pocket. It includes copays, coinsurance, and deductibles, but not premiums or costs for non-covered services.

Medicare Plan Members

For Medicare plan members, cost sharing may apply for some COVID-19 related services after May 11, 2023.

Out-of-State Members

For Kaiser members outside California, providers are subject to federal rules. After May 11, 2023, they will no longer be required to cover COVID-19 tests, treatment, or vaccines obtained out-of-network.

Clinical Diagnostic COVID-19 Tests Conducted by Licensed Providers

Basic HMO and PPO plans after November 11, 2023:

  • No member cost share for in-network services
  • Cost-sharing will apply for services received out-of-network

Medicare Advantage plans after May 11, 2023:

  • No cost for the test itself, but cost-sharing may apply for the doctor’s visit

Medicare Supplement plans after May 11, 2023:

  • No cost for the test or doctor’s visit

At-Home COVID-19 Tests

The federal government will continue to provide free at-home tests while supplies last. Visit covidtests.gov to get free COVID-19 antigen self-tests delivered to your home.

Using your CalPERS health benefits, at-home COVID-19 tests purchased outside CalPERS preferred pharmacies will be reimbursed up to $12 per test by completing and submitting a claim form to OptumRx, Kaiser, or Blue Shield directly.

  • Kaiser Permanente and Blue Shield will provide tests through their standard pharmacy procedures. Visit Kaiser and Blue Shield for this information.
  • Pharmacy Benefits for Sharp Direct Advantage is administered by the Pharmacy Benefit Manager CVS Caremark.
  • UnitedHealthcare Medicare Advantage (MAPD) members use the Medicare Part D claim form for reimbursement.

OptumRx acts as the Pharmacy Benefit Manager for the following CalPERS health plans:

  • Anthem Blue Cross, Traditional & Select HMO
  • Anthem Blue Cross EPO (Del Norte)
  • Health Net Salud y Más
  • PERS Gold and PERS Platinum PPO plans (Basic, PDP, and Medicare Supplement)
  • Sharp Health Plan Performance Plus
  • UnitedHealthcare Medicare Advantage Edge
  • UnitedHealthcare SignatureValue Alliance and SignatureValue Harmony
  • Western Health Advantage HMO and MyCare Select Medicare HMO

These health plans can use the Optum Store or OptumRx in-network preferred pharmacies such as Rite Aid, Sam’s Club, and Walmart.

Basic HMO and PPO plans after November 11, 2023:

  • No member cost share for tests obtained from in-network providers
  • Health plan's Pharmacy Benefit Manager to pay or reimburse for eight at-home tests per month. Ask your health plan for details.
  • Cost-sharing will apply for tests obtained out-of-network

Medicare Advantage and Supplement plans after May 11, 2023:

  • No member cost share for tests obtained from in-network providers
  • Health plan's Pharmacy Benefit Manager to pay or reimburse for eight at-home tests per month. Ask your health plan for details.
  • Cost-sharing will apply for tests obtained out-of-network

Outpatient COVID-19 Treatment in California (e.g., Paxlovid)

Basic HMO and PPO plans after November 11, 2023:

  • No member cost share for in-network services
  • Cost-sharing will apply for services received out-of-network

Medicare Advantage plans after May 11, 2023:

  • No cost for the test itself, but cost-sharing may apply for the doctor’s visit

Medicare Supplement plans after May 11, 2023:

  • No cost for the test or doctor’s visit

COVID-19 Vaccines & Boosters

All CalPERS members will continue to have access to COVID-19 vaccines and boosters at no cost under preventive benefits.

Additional Resources