Ed MacConnell
 

As communicated previously, the federal government’s requirement for health plans and self‑insured employers to cover the costs for FDA authorized over‑the‑counter (OTC) COVID‑19 tests began January 15, 2022. Independence is pleased to inform you of our plan to work with our clients to ensure coverage of these test kits for our members, through pharmacy benefits.

Independence coverage for OTC, at‑home COVID‑19 tests

Since they became available, Independence has covered testing to diagnose a COVID‑19 infection when ordered by a health care professional. Now Independence is covering up to eight OTC at‑home tests per member per calendar month when the tests are for personal use to diagnose a COVID‑19 infection, in alignment with the federal requirement.

This new mandate applies to fully insured and self‑insured plans. Independence will administer this coverage for clients that have pharmacy coverage with us through FutureScripts/Optum. This coverage will be available through the end of the federal Public Health Emergency, currently extended until April 16, 2022.

It is important to understand that to ensure only eight tests per member per month are processed, using one benefit program will be ideal. For any group clients that use a PBM other than FutureScripts/Optum, we are assuming they will be using their PBM for coverage of the tests. If they do not want to use their PBM and wish to process reimbursement claims through the medical coverage, they need to inform their Independence account executive of this decision.

Processing the test kit claims through the medical benefit will not meet the safe harbor requirements as set forth by the federal government, and therefore, the reimbursements that self‑funded groups will pay will not be limited to the $12 per test max, as outlined in the rule.

How members can obtain OTC at‑home tests through Independence/FutureScripts

Members who have FutureScripts/Optum drug coverage will have the most consumer‑friendly experience by getting their test kits at Rite Aid, Walmart, or Sam’s Club pharmacy counters, using their pharmacy benefits. Other information to help members:
  • By using Rite Aid, Walmart, or Sam’s Club members won’t need to pay for the tests, save receipts, submit claims, or wait for reimbursement when obtained this way. They can expect to present their member ID card at the pharmacy counter to have their test kit(s) processed through the pharmacy benefit.
  • Members can also order tests online via the Optum Store, beginning January 31. In the next week, we will provide additional information and the link that members can use.
  • Members do not need a doctor to prescribe these at‑home tests.*
  • Members can also purchase tests from other in‑store or online retailers (outside of Rite Aid, Walmart, or Sam’s Club); however, if they do, they will need to submit a pharmacy claim form with receipt to FutureScripts/Optum for reimbursement. Members will be reimbursed for the cost they paid for the test or $12 per test, whichever amount is lower.
  • Regardless of how members get the tests — retail or online — every member will be able to obtain up to eight tests each calendar month. However, due to supply shortages, retailers may limit the number of tests purchased at once.
  • Members who are covered under our FutureScripts/Optum pharmacy benefits will be receiving communications via mail, text message, or email about how to obtain test kits under their health coverage, in the coming weeks.

Which at‑home OTC COVID‑19 tests are covered?

At‑home OTC COVID‑19 tests that are authorized by the Food & Drug Administration are covered. These tests are taken at home and the results are read at home, without involving a health care professional or lab.

What will this cost self‑funded employer groups?

For the Preferred Network, pricing will be based upon Rite Aid’s, Walmart’s, Sam’s Club owned pharmacies Usual & Customary (U&C) submissions, plus a $0.50 dispensing fee per claim. This $0.50 dispensing fee replaces the existing contracted dispensing fee for these test kits. There will also be a $2 per claim administrative fee. The $2.50 fee (administrative and dispensing) is assessed per claim, not per test. So, if a member submits a claim for one test or eight tests, the total fee (administrative and dispensing) assessed is the same: $2.50.

For Direct Member Reimbursement (DMR) claim pricing will be processed at a cost of up to $12 per test with a $2 per claim administrative fee. The $2 administrative fee is assessed per claim, not per test. So, if a member submits a DMR claim for one test or eight tests, the total fee assessed is the same: $2.

In addition to the eight tests covered by insurance, the federal government has also made four OTC tests per home available, for delivery through the United States Postal Service, at https://www.covidtests.gov/.

What can members do to protect against COVID‑19?

We strongly encourage members to follow the advice of respected physicians and public health experts to get vaccinated and boosted. Vaccination is the most effective action we can take to collectively protect our own well‑being and that of our communities. COVID‑19 vaccinations and boosters continue to be available to members at no cost through Independence health coverage.

Please stay tuned for more information. In the meantime, please see our FAQs for Independence accounts and FAQ for Independence Administrators accounts. We will add new information to these questions and answers as it becomes available.

As always please contact your health insurance specialists at Total Benefit Solutions, Inc (215)355-2121 with any further questions