Pharmacy Benefit Plans FAQ: Coverage Essentials

Author

Article Summary

COVID-19 is now managed through standard pharmacy benefit plan design, but employers still need to monitor coverage, access, utilization, and supply risk. This FAQ explains how plans typically cover vaccines and antiviral treatments, manage refills and 90-day fills, respond to drug shortages, and align pharmacy strategy with cost control and population health priorities.

Contact Us

Whether you have a simple question, or a complicated one, we’re here to help.

Benefits leader reviewing pharmacy benefit plan data, vaccine coverage, specialty drug utilization, and cost-management insights.

You asked. OneDigital answered. 

While COVID-19 is no longer classified as a public health emergency, it remains an ongoing respiratory illness with seasonal trends. Pharmacy benefit plans have evolved from emergency response to standardized, sustainable coverage models for vaccines, treatments, and supply chain management. 

How are pharmacy plans covering COVID-19 vaccines and treatments today? 

Answer: 

COVID-19 vaccines are now treated similarly to other preventive vaccines (e.g., influenza): 

Coverage: 

Most plans cover COVID-19 vaccines at $0 cost-share when administered in-network, consistent with preventive care guidelines. 

Coverage may fall under medical or pharmacy benefits, depending on plan design and site of care (e.g., pharmacy vs. provider office). 

Boosters: 

Updated/seasonal boosters are typically covered in alignment with CDC recommendations. 

Treatments: 

FDA-approved antiviral treatments (e.g., oral antivirals) are now part of standard formulary management. 

These medications are generally placed on preferred or specialty tiers, with applicable copays or coinsurance. 

Utilization management (e.g., prior authorization) may apply based on clinical criteria. 

Key shift from 2020–2022: 
COVID vaccines and treatments are no longer handled as emergency-use exceptions, they are now fully integrated into traditional benefit structures and formularies. 

Are PBMs still allowing early refills or extended supplies for medications? 

Answer: 

Emergency refill policies implemented during the pandemic have largely expired. Current approach: 

Standard dispensing rules apply (e.g., refill-too-soon edits reinstated). 

Most plans continue to encourage: 

  • 90-day maintenance fills  
  • Mail-order programs  
  • Auto-refill programs  

Exceptions: 

May still be granted on a case-by-case basis (e.g., travel, natural disasters, or clinical need). 

Best practice: 
Plans are focusing on adherence and cost efficiency, rather than stockpiling medications.

What is the current impact of global drug manufacturing and supply chains? 

Answer: 

The pharmaceutical supply chain has stabilized compared to early pandemic disruption, but ongoing risks remain: 

Global dependency continues: 

A significant portion of active pharmaceutical ingredients (APIs) are still sourced internationally (e.g., China, India). 

Current state: 

No widespread COVID-driven shortages 

However, targeted drug shortages (e.g., injectables and certain generics) continue due to: 

  • Manufacturing constraints  
  • Demand surges  
  • Regulatory or quality issues  

Employer impact: 

Potential cost volatility for high-demand therapies 

Increased importance of: 

PBM response: 

  • Active management of shortages through: 
  • Therapeutic alternatives  
  • Prior authorization controls  
  • Quantity limits  

Key takeaway: 
Supply chain disruption is no longer COVID-driven—but structural vulnerabilities still require active management. 

Are there any new or emerging COVID-related considerations for employers? 

Answer: 

Yes, while the emergency phase has passed, employers should still monitor: 

  • Seasonal COVID trends (similar to flu/RSV planning)  
  • Vaccine strategy alignment (e.g., encouraging annual boosters for at-risk populations)  
  • Workplace health policies (generally relaxed but adaptable if needed)  
  • Integration with broader respiratory illness strategy (flu, RSV, COVID combined approach)  

What should employers be doing now from a pharmacy strategy perspective? 

Answer: 

Employers should treat COVID as part of a holistic pharmacy and population health strategy: 

  • Ensure preventive vaccine access remains easy and low-cost  
  • Monitor formulary placement and utilization management of COVID therapies  
  • Leverage PBM and vendor partners for:  

As pharmacy strategies continue to evolve, employers that take a proactive and data-informed approach are better positioned to manage costs, improve outcomes, and reduce risk over time. 

Connect with a OneDigital Pharmacy Benefits Expert to evaluate your strategy and identify cost-saving opportunities.

Publish Date:Jun 25, 2026Categories:Employee Benefits