• Paul Peter Nicolai

OTC COVID Test Coverage Required of Health Plans

Updated: Feb 15

The Department of Labor, Department of Health and Human Services, and the IRS (the “Agencies”) have issued Frequently Asked Questions #51 (“FAQs”) on implementation of the Families First Coronavirus Response Act, and the Coronavirus Aid, Relief, and Economic Security Act. They say that group health plans and health insurance issuers must cover over-the-counter (“OTC”) COVID-19 tests. Plans and issuers must cover these OTC COVID-19 tests even though the tests are obtained without the involvement of a health care provider. This coverage must be provided without imposing any cost-sharing requirements, prior authorization, or other medical management requirements This rule does not require a plan or issuer to provide coverage by reimbursing sellers of OTC COVID-19 tests directly. A plan or issuer may instead require a participant, beneficiary, or enrollee who purchases an OTC COVID-19 test to submit a claim for reimbursement to the plan or issuer. Plans or issuers that provide coverage through both their pharmacy network and a direct-to-consumer shipping program, may limit reimbursement for OTC COVID-19 tests from nonpreferred pharmacies or other retailers to $12 per test. The plan or issuer may limit the number of OTC COVID-19 tests for each participant, beneficiary, or enrollee to 8 tests per 30-day period (or per calendar month). However, the Agencies note that this limit applies only with respect to the coverage of OTC COVID-19 tests that are administered without a provider’s involvement or prescription; “plans and issuers must continue to provide coverage for COVID-19 tests that are administered with a provider’s involvement or prescription.” These rules apply to tests purchased on or after January 15, 2022.

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