Aetna provided the following information to their small group plan sponsors regarding coverage for OTC COVID-19 tests. Click here for a PDF version of this information from Aetna.
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:
- 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).
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.
Aetna's strategy for compliance
While Aetna can administer the required coverage of OTC COVID-19 tests in various ways, due to the urgency of this mandate, Aetna has made the decision to cover OTC tests under the pharmacy benefit.
Aetna is immediately implementing the strategy below for your pharmacy plan to help ensure you have a path to compliance beginning January 15, 2022.
- 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 Aetna has further details. Claims will initially be reimbursed at the billed cost until the direct coverage arrangement is in place.
- Direct Coverage: Aetna is working to implement this arrangement through their 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. Aetna 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, Aetna will contact plan sponsors about the direct coverage option and provide details for members to submit direct reimbursement claims. They will include a proposed member communication.
For questions, please contact a member of your B&P Sales Team - 888.722.3373.