Answers to questions about coverage of OTC At-Home COVID-19 tests for our clients and partners

What is the Serve You Rx recommendation for coverage?

On January 10, 2022 the U.S. Departments of Labor, Health and Human Services, and Treasury issued guidance pertaining to over-the-counter (“OTC”) at-home COVID-19 tests, including the requirement that health plan coverage for these products must be in place by January 15, 2022.

Effective January 15, 2022, commercial health plans must provide coverage of OTC at-home COVID-19 test kits with no copay, cost share, or deductible. This requirement applies to grandfathered and non-grandfathered Health Plans. Further, it is encouraged that health plan members be provided with a “direct coverage” option, which allows kits to be picked up at a pharmacy or shipped to home without the need for upfront payment and subsequent reimbursement.

Effective January 15, 2022, OTC At-Home COVID-19 tests that are dispensed to eligible Plan Members by Serve You Rx network pharmacies or the Serve You DirectRx Mail Service Pharmacy and submitted electronically to Serve You Rx will be covered directly, subject to an 8 test per 30 days per member quantity limit, and with the required $0 member cost share.

Plan members who pay out-of-pocket for OTC at-home COVID-19 test kits may also seek reimbursement, subject to the quantity limits outlined above, by submitting a pharmacy receipt to Serve You Rx through the standard Direct Member Reimbursement process.

What is the cost to a member for OTC at-home COVID-19 tests?

There is no cost-sharing ($0 copay) for OTC at-home COVID-19 tests claims that are submitted electronically to Serve You Rx by an in-network pharmacy.

If an OTC at-home COVID-19 test is purchased by the member at a pharmacy, the member may seek reimbursement from the plan via Direct Member Reimbursement and is eligible for reimbursement up to $12 per test.

What is the cost to the plan for OTC at-home COVID-19 tests?

1. When plan members obtain OTC at-home COVID-19 tests via electronic claim submission by a network pharmacy, the health plan will be billed for the cost of the testing kit plus the pharmacy dispensing fee. The cost of the OTC at-home testing kit will be specific to the product dispensed.
2. When plan members obtain OTC at-home COVID-19 tests by paying out-of-pocket and seeking Direct Member Reimbursement, they will be reimbursed and the health plan will be billed for the lower of the pharmacy’s Usual and Customary price or $12 per test.

Can my plan opt-out?

Based on guidance from the federal government and the CARES Act, coverage is required for OTC at-home COVID-19 testing kits for both grandfathered and non-grandfathered plans. However, this coverage may be provided via the pharmacy benefit, the medical benefit, or both. Effective January 15, 2022, OTC at-home COVID-19 tests that are dispensed to eligible plan members by Serve You Rx network pharmacies or the Serve You DirectRx Mail Service Pharmacy and submitted electronically to Serve You Rx will be covered directly for all Serve You Rx commercial self-funded plans, non-grandfathered and grandfathered. If your health plan wishes to opt-out of this coverage for OTC at-home COVID-19 tests, please reach out to your Clinical Account Executive or send an email to clientinquiry@serveyourx.com.

Will members need a prescription to receive the OTC at-home COVID-19 tests at a pharmacy?

No prescription is required for OTC at-home COVID-19 tests.

Are there any limits on how many OTC at-home COVID-19 tests can be filled through the plan?

No prior authorization or other utilization management may apply, except that health plans may limit the number of COVID-19 tests per plan member to a maximum of eight tests per 30 days.

Coverage is only available for personal use. Members should not request reimbursement from the prescription drug plan for OTC at-home COVID-19 tests for non-personal use.

Where can members get the OTC at-home COVID-19 tests?

In order to obtain OTC at-home Covid-19 test kits without upfront payment, the member must go to an in-network pharmacy and the pharmacy must be able to electronically submit a claim to Serve You Rx for the test kit in question.

NOTE: There may be circumstances where a commercially available OTC at-home COVID-19 test kit is not listed in the pharmacy’s system or is otherwise unable to be electronically billed. Under these circumstances, the member should seek reimbursement through the Direct Member Reimbursement process.

Under the Direct Reimbursement Process, members should submit a pharmacy receipt that includes prescription number with the Prescription Claim Reimbursement form that is available on the Serve You Rx website at: https://serve-you-rx.com/members/serve-you-rx.com.

The Serve You Rx Direct Member Reimbursement process is limited to OTC at-home COVID-19 tests obtained from a pharmacy. OTC at-home COVID-19 tests that are obtained elsewhere, such as from the front of the store, sold as a general purchase (not a pharmacy purchase), sold at a grocery store, sold at a sundry outlet, or sold at a gas station are not eligible for reimbursement under the prescription drug plan.

The Serve You DirectRx Mail Service pharmacy has purchased inventory of OTC at-home COVID-19 tests, which will be available soon. Members will be able to utilize the DirectRx Pharmacy as a direct shipping option for OTC at-home COVID-19 tests and the DirectRx Pharmacy will be able to bill your plan directly.

Coverage may be available under the medical benefit, such as for OTC at-home COVID-19 tests that are purchased from a non-pharmacy entity. Please consult with your medical benefit provider for information regarding coverage under the medical benefit.

It is the current Serve You Rx opinion and recommendation based on discussions with CMS, industry organizations, and other health care experts, that the strong emerging consensus is that these tests are to be primarily covered on the prescription drug benefit. Furthermore, to extend coverage to both the medical and pharmacy benefits will make enforcement of the eight tests per 30 day limit difficult or impossible, resulting in the potential for additional unnecessary coverage.

Where can members get information about the OTC at-home COVID-19 tests?

Member information and FAQs are available on the Serve You Rx website. We also encourage members to refer to the CDC website (cdc.gov), local health authority or public health department, and the member’s prescriber or local pharmacist.

Where can I get more information? Who can help me if I have a clinical question? (e.g., Should I use an OTC at-home COVID-19 test? Are the tests safe and reliable?)

For more information, please refer to the CDC website (cdc.gov), your local health authority or public health department, your doctor, or your local pharmacist. For a clinical question, please reach out to your Serve You Rx Clinical Account Executive or clientinquiry@serveyourx.com.

 

FOR MORE INFORMATION

CDC’s website on Coronavirus Disease

FDA EUA website

Department of Labor, Health and Human Services, and Treasury FAQ

Centers for Medicare and Medicaid Services FAQ