Vaccine Mandates and At Home COVID-19 Testing Kits

Last week there were several developments surrounding the large employer vaccine mandate and the mandate for health plans to cover COVID-19 at home test kits.  A summary of these is outlined below.

Large Employer Vaccine Mandate

Background – The Biden Administration through OSHA released Emergency Temporary Standard (ETS) rules for employers with 100 or more employees to mandate the COVID-19 vaccine or require weekly mandatory testing beginning in January.  The 6^th Circuit Court of Appeals issue an injunction against the mandate.  This was later overturned by the 5^th Circuit Court of Appeals.  Following that action, the case went to the Supreme Court.

Where We Are Today – In a 6-3 decision, the Supreme Court blocked the OSHA ETS mandate.  Employers with 100 or more employees are no longer required to mandate vaccines or weekly testing.  Please note, however, that this ruling does not impact State, Municipal or contractual requirements for vaccines, testing and/or masking and does not prohibit companies from having a policy that requires vaccines, testing and/or masks.  The Supreme Court did uphold the CMS Vaccine Mandate that applies to all healthcare providers that receive federal Medicare or Medicaid funding.

Insurance Coverage for At Home COVID-19 Testing Kits
FDA approved at home COVID-19 tests purchased on or after January 15, 2022, and throughout the public health emergency, are required to be covered by your Plan. Tests will be covered without imposing any cost sharing, prior authorization, or other medical management requirements.  A quantity limit will be set at the participant, beneficiary, or enrollee level of 8 OTC tests per 30-day period (or calendar month).  In the event a member obtains an OTC test kit that contains more than one individual test, it shall count as the number of individual tests toward the monthly maximum.  (For example, a member could obtain 8 individual tests or 4 test kits that contain 2 individual tests each per month).

COVID-19 at home test kits will be covered under your plan’s pharmacy benefit only and not through major medical.  Each Pharmacy Benefit Manager has developed a process around how to handle these claims.

EmpiRx Health:
In-Network

• OTC testing kits will be covered under the pharmacy benefit and not under medical benefits.
• Tests will be covered at point of sale at zero member cost for claims through the existing EmpiRx Health pharmacy network (the Diversified/EmpiRx network has over 63,000 pharmacies).
• Members would need to present their prescription card at the pharmacy register when obtaining the OTC test kit.
• OTC tests must be FDA-approved versions and will be billed to plan sponsors at the amount charged by the pharmacy.
• Up to 8 tests per member per month will be covered.

Out-of-Network
Tests purchased out of network (not within the EmpiRx network) will only be reimbursed the lesser of the cost of the test or $12 per test.  Tests must be FDA-approved to qualify for reimbursement.   Members who purchase a test outside of their pharmacy’s network will have to purchase the test and then submit their receipts with a claim form stating what test was purchased.  Receipts for OON claims must be filed with a Direct Member Reimbursement form from EmpiRx and sent to the address on the form.

OptumRx:
In-Network

• OTC testing kits will be covered under the pharmacy benefit only and not under medical benefits.
• Tests will be covered at point of sale at zero member cost for claims through the existing OptumRx pharmacy network at Walmart or Rite-Aid Pharmacies only.  Walmart or Rite-Aid Pharmacy will be the OptumRx preferred retail pharmacy for OTC at home testing kits.
• Members would need to present their prescription card at the Walmart or Rite-Aid Pharmacy register when obtaining the OTC test kit.
• OTC tests must be FDA-approved for Emergency Use Authorization and will be billed to plan sponsors at the amount charged by the pharmacy in accordance with the OptumRx-Walmart contracted pricing.  Additionally, OptumRx will bill a $2.00 administrative fee per claim.
• Up to 8 tests per member per month will be covered.
• OptumRx is looking to expand their in-network coverage as more pharmacies become operationally prepared.  We will keep you updated to any expansion of this network.

Out-of-Network
Tests purchased out of network (not through the OptumRx Walmart or Rite-Aid Pharmacy network) will only be reimbursed the lesser of the cost of the test or $12 per test.  Tests must be FDA-approved for Emergency Use Authorization to qualify for reimbursement.  Members who purchase a test outside of the Walmart pharmacy network will have to purchase the test and then submit their receipts with a claim form stating what test was purchased.  Receipts for OON claims must be filed with a Direct Member Reimbursement form from OptumRx and sent to the address on the form.

Click to find member facing communication pieces you can use to distribute to your employees for either EmpiRx or OptumRx.

As this issue develops, we will continue to keep you updated.