Starting this weekend, Californians may face additional costs for COVID-19 vaccines, treatments and testing outside their health plan network — a potential unwelcome surprise for those who’ve put off that shot but plan to get it before Thanksgiving.
Under the federal public health emergency, medical plans were required to provide the shots, treatments and tests to people without added costs. That federal health emergency ended May 11, but California law required plans to continue covering COVID vaccines, treatments and testing even outside their networks for six months after the health emergency expired.
Now that moment has come, and starting Sunday those who seek COVID care outside of their health plan networks — which might happen if your provider doesn’t have the vaccine in stock or appointments are backed up — may end up having to pay for it.
“After November 11, which is six months after the end of the public health emergency, enrollees can be charged cost-sharing if these services are provided out-of-network,” the California Department of Public Health said.
And that could be a decent chunk of change. According to the Centers for Disease Control and Prevention, the Pfizer shot costs $115, and a dose of Moderna will set you back $128.
The CDPH said that the vaccines will continue to be free for most people at sites within the network of their health insurance plans, including Medi-Cal and regular health care providers. Each plan will have its own policies, and the CDPH urged people to contact their health insurer.
The change comes after federal health authorities in September authorized a new COVID-19 vaccine tailored to one of the recent omicron virus variants, XBB.1.5. The new shot replaced the previous “bivalent” vaccine that was based on both the original virus strain and an earlier BA.4 and BA.5 omicron variant.
COVID vaccines that were created for the original and now nonexistent strain no longer are in use. The CDC has recommended the new vaccine for everyone six months and older.
But it’s not clear how much demand there’s been for it. The CDPH’s vaccine tracking indicates that as of Nov. 1, just 6.7% of Californians are “up to date” on COVID-19 vaccination, though figures are higher in the Bay Area. A Kaiser Family Foundation poll in September found that fewer than half of adults planned to get the latest COVID shot, and 1 in 4 previously vaccinated said they wouldn’t.
COVID hospitalizations in California, though trending upward in recent weeks, remain significantly lower than the last peak in September and well below levels during the pandemic in recent years.
Kaiser Permanente, which operates three dozen hospitals and more than 500 medical offices throughout California, sent notices to its members that “you’ll still get COVID-19 care at no cost from Kaiser Permanente,” including vaccines, treatments, molecular tests and up to eight home antigen tests a month.
But Kaiser advised that while its members who get COVID-19 care from out-of-network providers will need to pay, they may be able to get up to half of the cost reimbursed if they submit a claim, and that care administered as part of urgent or emergency treatment may be eligible for full reimbursement.
Blue Shield said the transition this weekend won’t change how Blue Shield members access COVID vaccines, testing or Paxlovid treatment. But its members will have to start paying out-of-pocket costs for COVID services rendered out of network.
National pharmacy chain Rite Aid said in a statement that “COVID-19 vaccines are available at no cost through most insurance plans” but that “customers should check with their insurance plan to learn more about their vaccine coverage.”
No-cost vaccines are available for uninsured and underinsured adults through the CDC’s Bridge Access Program and for children who otherwise would not be able to pay through the Vaccines For Children program.
CVS pharmacies said in a statement that the updated COVID-19 vaccine is available at no-cost at CVS pharmacies through most insurance plans, and that CVS is participating in the Bridge Access Program to provide free COVID-19 vaccinations to the uninsured adults and adults who are in-network where their insurance does not cover all COVID-19 vaccine costs.
Appointments for COVID-19 vaccinations can be scheduled through the state’s MyTurn.ca.gov site, the federal government’s vaccines.gov page, local pharmacies or health care providers.
COVID treatments such as Paxlovid and Lagevrio are also undergoing changes this month that could affect your pocketbook. Federally purchased COVID-19 medications that are still in supply will remain free to all patients regardless of their insurance status, and that supply is expected to last through the end of the year in most areas.
But once that supply runs out, the price of those treatments will depend on the patient’s insurance as the drugs are shifted to the commercial market. Both Paxlovid and Lagevrio will offer Patient Assistance Programs to assist patients who would otherwise not be able to afford their prescription. There will also be a Paxlovid co-pay savings program for eligible commercially-insured patients.
That’s significant because treatment costs can be substantial — Pfizer has priced the five-day Paxlovid treatment at $1,390.
For COVID testing, you still can order four free at-home COVID-19 tests by mail through the federal government at covid.gov/tests, or by calling 1-800-232-0233.
