January 1 RxAdvocate January, 2022 — Newsletter
January COVID Updates:
- At-Home Test Coverage
- Oral Antiviral Medication
Effective January 15, 2022, the Biden Administration requires plan sponsors to cover the cost of athome
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, our 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 diagnosis
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 up to $12 for tests purchased outside of the preferred
network.
How will the 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 administration and dispensing fees may apply depending on your 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 we allow coverage 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
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, there is no legislation that mandates a $0 member copay
How will with 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 additional information on oral antiviral medications, please click here.
Contact us
Orlando.Neal@rxconnectionllc.com