COVID-19 Alert: OTC Testing Coverage and Therapeutics Policies

The federal government issued a public notice requiring commercial health plans to cover up to eight at-home testing kits per month per covered individual for diagnostic use starting January 15 and continuing through the Coronavirus public health emergency period, which has been extended to April 15, 2022.

Coverage and Purchase of Over-the-Counter (OTC) Testing Kits, Quantity Limits

Cigna Individual and Family Plans medical plan customers may receive reimbursement for up to eight OTC COVID-19 tests per covered individual per calendar month without a health care provider prescription or individualized clinical assessment. Health plans may count each test separately, even if multiple tests are sold in one package; i.e. if one package includes eight tests, it counts as eight tests and not one test package toward the quantity limit.

In the early stages of implementing the process to comply with the mandate, Cigna Individual and Family Plans medical health plans will cover eligible over-the-counter COVID-19 tests as a medical benefit. This means customers will pay for tests out of pocket, complete a claim reimbursement form, attach the receipt, and submit these items by mail or fax for reimbursement.

The COVID-19 Over-the-Counter (OTC) Test Kit Claim Form can be downloaded from //Cigna.com/Coronavirus and myCigna.com. The form includes the customer attestation stating use is for diagnostic purposes and lists some of the FDA EUA designated OTC at-home tests eligible for reimbursement.

According to the federal mandate, health plans must refund the full purchase price of the test. Cigna will determine and apply any and all fraud policies. Cigna will continue to evaluate options within the mandate to further simplify the process for customers to acquire tests and help control health plan costs.

Cigna Individual and Family Plans medical plans will continue to cover COVID-19 tests performed by health care providers for diagnostic purposes and those tests are not subject to this quantity limit.*

COVID-19 OTC tests purchased prior to the Jan. 15, 2022 are not eligible for reimbursement.

Customer Reimbursement

According to the federal mandate, health plans must reimburse the costs of diagnostic OTC testing, regardless of where it was obtained (in- or out-of-network). Cigna has established a process to comply with the mandate to reimburse customers for the OTC tests purchased on or after January 15, 2022.

What is the safe harbor rule?

The safe harbor applies if plans that provide access to OTC tests through a pharmacy network and a direct-to-consumer shipping program, under which there is no upfront out-of-pocket expenditure by the participant.

The federal government is not expecting the preferred pharmacies in a plan’s “direct coverage” solution to represent the entire plan’s entire pharmacy network, but has stressed that the plan must nevertheless ensure adequate access to OTC tests, including as it relates to retail pharmacies.

Cigna is evaluating safe harbor rules and will communicate further guidance.

To help you inform your clients about this reimbursement process and answer other important questions, please download and share this flyer.

If you or your clients have questions about the differences in the various testing types, please visit the CDC web site for more information: COVID-19 Testing: What You Need to Know | CDC

Coverage for COVID Antiviral Oral Therapeutic Drugs

Late December 2021, the FDA approved COVID-19 antiviral therapeutic medications, Paxlovid (Pfizer) and Molnupiravir (Merck), to help reduce the severity of the virus. The government bought these therapies and is distributing them free of charge. Cigna will cover the medications on all formularies immediately. Customers will pay a $0 ingredient cost when supplied and funded by the government or when obtained at a pharmacy.

A COVID therapeutic locator has been established by the government and can be accessed here.

No Prior Authorization will be required. As with all COVID EUA products, COVID policies will be updated to include clinical guidance on when to use each product per specifications of the EUA.