On Jan. 30, 2023, the Biden Administration announced it will end the public health emergency declarations on May 11, 2023. Here’s what will change when the public health emergency ends.
Since the onset of the pandemic, Evernorth and Express Scripts PBM have worked with plan sponsors to build a comprehensive response based on data and clinical knowledge to keep members healthy and safe. There’s no easy answer to the challenges faced due to the COVID-19 pandemic. What we do know is that you need a diverse set of capabilities to move forward. We’re here to help you navigate your next steps.
Over-the-counter home test kits
Starting May 12, 2023, plan sponsors are no longer required to pay for COVID-19 over-the-counter (OTC) tests. But, just because it’s not required doesn’t mean it’s not a valuable benefit to offer. At a fraction of the cost of PCR tests utilized at hospitals and clinics, our standard and newly customizable OTC testing product options meet your need for affordability and your members’ need for convenience while the virus persists in their communities.
A positive test helps your members get treated faster and take steps to minimize the spread of the virus. OTC tests can also be used to show negative results if required for work, school, travel, visiting family in a nursing home, and many other reasons.
Under Section 2713 of the Affordable Care Act (ACA), non-grandfathered private insurers and self-insured employer plans must provide coverage for a range of recommended preventive services and may not impose cost-sharing (such as copayments, deductibles, or co-insurance) on patients receiving these services from in-network providers.
The preventive services guidelines require COVID-19 vaccination and booster shot coverage for adults and children, which are recommended and determined to be for routine use by the Advisory Committee on Immunization Practices (ACIP).
Coverage for COVID-19 vaccines will continue post PHE for all plan sponsors currently enrolled in the Pharmacy Vaccination Program.
COVID-19 Oral Antiviral Therapeutics Program
Antivirals will see no changes post-PHE. We will continue coverage consistent with plan sponsors current enrollment until a commercial product is available. The U.S. Food and Drug Administration (FDA) has not yet approved these drugs. The only product currently available is under an emergency use authorization (EUA). While timing for antivirals is still unknown, once a commercial product is available, we expect claims will process in accordance with each plan sponsor’s formulary and copays.
Pharmacists have been granted new prescribing authority from the FDA, allowing them to prescribe PAXLOVIDTM to eligible patients testing positive for COVID-19. Therefore, Express Scripts PBM has built the capabilities to offer Direct to Patient Prescribing for Paxlovid as an add-on option under our Oral Antiviral Therapeutics Program. Under this program, when Paxlovid is prescribed and dispensed by a pharmacist, the savings are substantial, for both plans and patients. Members have access to participating pharmacies nationwide with the possibility of a $0 copay. Plan sponsors can expect up to a 50% decrease in plan spend when members see a pharmacist vs. a physician for a Paxlovid prescription. Plan sponsors can save even more when members avoid an Emergency Room visit just to get a Paxlovid prescription. Plus, members with a physician office copay can pocket that money by seeing a pharmacist for $0 copay instead.
If you’re not offering COVID-19 coverage to keep your members healthy and safe, considering signing up today.
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Evernorth COVID-19 Vaccination Clinics
With the help of Evernorth, you can bring dedicated clinics to any location, such as your worksite, or reserve vaccinations in store at a local retail pharmacy. We do all the heavy lifting—scheduling the pharmacy provider, providing employee outreach and more—making it easy for you to bring vaccines to your members.
Evernorth Pharmacy Vaccination Program
The Evernorth Pharmacy Vaccination Program makes sure members are covered when they get vaccinated at a pharmacy, an on-site clinic, or other location, and claims are processed through their pharmacy benefit. Enrolled plan sponsors receive a digital vaccination toolkit to help inform and empower members to get their vaccine.