January 10, 2022, the U.S. Department of Labor (DOL) issued guidance related to insurance coverage for COVID OTC testing, provided at no cost to covered individuals that was effective as of January 15, 2022.
COVID 10 Home Testing Highlights
- Beginning January 15, 2022, most individuals with health insurance can purchase at home over-the-counter COVID-19 diagnostic tests at no cost to them either through submitting a receipt or free of charge through their insurance provider.
- The Families First Coronavirus Response Act, section 6001 requires plans to cover COVID-19 tests that have been authorized and cleared or approved by the FDA. Under this Act plans are not allowed to impose any cost-sharing requirements, prior authorization, or other medical management requirements.
- Plans, often working through their PBM, will establish a process whereby the test will be available at no charge to the individual at point of sale. Plans may also provide reimbursement to the individual when the individual pays up front for the test kit.
- Some plans can cap the reimbursement amount if the plan has set up a network of preferred retail outlets (stores, pharmacies and/or online retailers). When a plan establishes such a network and an individual purchases the kit outside of that network, the plan is required to reimburse the individual at a rate of up to $12 for each test. If the cost of a test is less than $12, then the reimbursement will be capped at the actual cost of the test.
- Plans are required to provide reimbursement for up to eight (8) tests per individual covered by the plan each month. This limit is regardless of whether the tests are purchased at one time or at separate times throughout the month.
- PBMs administer these benefits for many plans and have established different approaches to meet the requirements established by the Biden Administration. It is important to understand the approach used by your PBM. We have outlined a list below that summarizes the approach for some PBMs. This information below is intended to provide a sampling of approaches, you should consult your PBM for their specific approach and guidelines.
Summary of PBM Program Approaches for Sampling of PBMs
(Note this is not an exhaustive list):
- CVS: CVS/Caremark offers an opt-out program for plans to provide coverage for COVID-19 testing products to their members. The CVS/Caremark approach provides for direct reimbursement and direct reimbursement at in-network pharmacies. Plans will have until January 28, 2022 to opt out of the program. Contact your CVS account manager for program details.
- ESI: Express Scripts offers an opt-in program for plans to provide coverage for COVID-19 testing products to their members. Plans may be required to sign an amendment and will be required to accept the terms and conditions of the program. ESI’s approach will assess a COVID-19 Testing Product Program Fee in addition to other costs and fees set forth in the Agreement between ESI and the plan. Contact your ESI account manager for program details.
- Magellan: Magellan offers an opt-out program for plans to provide coverage for COVID-19 testing products to their members. The Magellan program provides coverage of FDA authorized, cleared, or approved OTC COVID-19 antigen tests at a zero-dollar member cost share for members who utilize an in-network pharmacy. Testing for employment purposes will not be covered. Magellan also provides reimbursement to members who have purchased an OTC Antigen COVID-19 test from an out-of-network pharmacy through their DMR process. DMR reimbursement will be the lesser of the actual price, or $12/test. For details plans should contact their Magellan account manager.
- Navitus: Navitus offers a book of business solution for plans to provide coverage of COVID-19 testing products to their members. The Navitus offering provides for direct reimbursement and direct reimbursement at point of sale at in-network pharmacies. The test kits will be covered at a reimbursement rate of up to $12 per test. For details plans should contact their Navitus account manager.
- OptumRx: OptumRx has published their approach for the handling of at-home COVID-19 testing products on their website. The most recent information can be found here >>
- ProAct: ProAct is offering a book of business solution with options for plans. If a plan does not want to participate they may opt out of the program. In order to opt out the plan needs to contact ProAct. Coverage will be for up to eight (8) tests per covered member per 30 days. No prescription will be required. Members will need to use a participating pharmacy. For details plans should contact their ProAct account manager.
