COVID-19 At Home Test Coverage FAQs

Effective January 15, 2022, the Biden Administration requires plan sponsors to cover the cost of at-home COVID-19 tests.

Members may receive coverage for eight at-home COVID-19 tests per 30 days with no copay, cost share or deductible. In response to this news, the OneDigital Pharmacy Consulting team has compiled a list of questions and answers to support you.

1. How do antigen tests compare to PCR tests?
   • The FDA has approved antigen and PCR (polymerase chain reaction) tests to diagnose COVID-19 infection.
   • Antigen tests produce same-day results but are not as sensitive as PCR tests, which may increase the risk of false results.
   • PCR tests are typically higher in cost and may take up to a few days to produce results.
2. Where can members find a test?
   • Members can purchase a test in-person at an in-network pharmacy or online.
   • Out-of-network pharmacies may also be used; however, reimbursement may vary depending on plan design.
   • For information on free tests that may be available through government programs, visit COVIDtests.gov. Tests will ship within seven to 12 days of ordering.
   • Several states have already started issuing free at-home COVID-19 tests to residents, including Colorado, Massachusetts, Iowa, Connecticut, Washington, New Jersey, Maryland, Ohio, Oregon and New Hampshire. Washington, DC, is making at-home tests available for pickup at area libraries while other cities like New York and Boston are distributing them to local health clinics.
3. What should the plan limit for reimbursement be?
   • Plans offering direct coverage may cover all costs in a network of preferred stores, pharmacies, and online retailers.
   • Reimbursement limits can be set to $12 for tests purchased outside the preferred network.
4. How will claims reimbursement and fees differ from standard claims?
   • Plan participants may have the ability to access at-home COVID test kits with direct coverage provided by processing through the pharmacy benefit at the time of purchase.
   • Additional admin and dispensing fees may apply depending on pharmacy benefit manager and plan-specific coverage.
5. Can members obtain reimbursement through a Direct Member Reimbursement Claim?
   • Yes, the member will need to go through the standard Direct Member Reimbursement process.
   • Check to see if your pharmacy benefit manager has created a specific form for at-home COVID-19 tests.
6. Will COVID-19 testing products be excluded from guarantees?
   • Claims for COVID-19 testing products shall be excluded from all financial and rebate guarantees under the PBM Agreement.
7. Is my plan required to provide direct coverage for at-home COVID-19 tests?
   • Plans are not required to provide direct coverage and may opt to require a member to submit a claim for reimbursement if they purchase an at-home COVID-19 test.
8. Should at-home COVID-19 tests be covered under medical and pharmacy?
   • We recommend pharmacy only coverage if/when possible to have more options for $0 cost at the point of sale and better management of the cost/limits vs. medical, which would be more reimbursement only based.

COVID-19 Oral Antiviral Medication

The U.S. Food & Drug Administration has approved two COVID-19 oral antiviral medications: Pfizer’s pill, PaxlovidTM, and Merck’s molnupiravir. If these medications are taken soon after the presentation of COVID-19 symptoms and a positive COVID-19 test, these medications can help reduce the severity of the virus, potentially reducing hospitalizations and deaths.

FAQs:

1. Am I required to cover these medications under the plan?
   • These medications were approved under Emergency Use Authorization (EUA), all plan sponsors are expected to cover them.
2. Is there a quantity limit?
   • Please check with your specific pharmacy benefit manager.
3. Are these medications mandated to be covered at $0?
   • Currently, no legislation mandates a $0 member copay.
4. How will the claims reimbursement and fees differ from standard claims?
   • The dispensing fee is passed through from the pharmacy, with the government paying the ingredient cost.

For more information and workplace resources, employers can leverage related to the pandemic, visit the OneDigital Coronavirus Advisory Hub.  As always, if you have additional questions pertaining to your plan or situation, please reach out to your OneDigital consultant.