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COVID-19 At Home Test Coverage FAQs
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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Is there a quantity limit?
- Please check with your specific pharmacy benefit manager.
- Are these medications mandated to be covered at $0?
- Currently, no legislation mandates a $0 member copay.
- 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.