Some news from the US that I would say is positive that was sent to me from HR.
Summary of requirements
On January 10, the Biden Administration issued guidance requiring all group health plans and health insurers to cover OTC COVID-19 tests without member cost share effective January 15, 2022.
The new OTC coverage requirement:
Note: This mandate is in effect until the end of the federal public health emergency. Any tests purchased pursuant to a physician’s order will not be subject to the quantity limit. This mandate does not apply to claims incurred outside the U.S.
- Allows consumers with commercial health coverage to seek reimbursement from their health plan for OTC tests they purchase online or in-person without the direct involvement of a health care provider.
- Requires health plans to cover, without cost sharing, up to 8 OTC tests per member per 30 days (if kits contain 2 tests, then no more than 4 kits per 30 days).
- Maintains the policy that plans are only required to cover tests intended for diagnosis or treatment (versus routine screenings for employment, school or recreational purposes).
Our strategy for compliance
While we can administer the required coverage of OTC COVID-19 tests in various ways, due to the urgency of this mandate, we have made the decision to cover OTC tests under the pharmacy benefit.
We are immediately implementing the strategy below for your pharmacy plan to help ensure you have a path to compliance tomorrow, January 15, 2022.
Coming soon
- Direct Member Reimbursement: Reimbursement for OTC COVID-19 tests without a prescription after purchase, starting January 15, 2022. Members should hold their claim submissions until we have further details. Claims will initially be reimbursed at the billed cost until the direct coverage arrangement is in place.
- Direct Coverage: We are working to implement this arrangement through our retail pharmacy network as soon as possible. Plan will cover the cost of the OTC tests with direct reimbursement to the pharmacy and no upfront out of pocket cost for members. We will adjudicate claims at a rate comparable to the pharmacy’s U&C rate. This is necessary to encourage broad pharmacy participation and adequate access to care.
Next week, we will contact you about the direct coverage option and provide details for members to submit direct reimbursement claims. We will include a proposed member communication.
So it looks like there is more information to come. Apparently this became effective Jan 15th, but I only just now received this.