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COVID-19 Over-the-Counter Test Kit Coverage Options

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On January 30, 2023, the White House released a Statement of Administration Policy announcing the Biden Administration’s intent to end the COVID Public Health Emergency (PHE) on May 11, 2023. At that time, plan sponsors will no longer be required to pay for COVID-19 tests over-the-counter (OTC) tests available at local pharmacies and online.

But, your members will still need OTC tests and they’ll look to you for help. We leverage our unmatched scale and proven track record of negotiation to keep test kits at a predictable and affordable price so you can meet your members’ need for continued access.

We need to know your desire for OTC test coverage now to ensure an easy transition when the PHE expires. 

Reach out to your Account Representative if you’d like to see carrier-level modeling, which estimates your 2023 forecast based on 2022 claim history, before making a decision.

PLEASE READ: Enrollment can only be completed at the Carrier Level. For sub-carrier level enrollment, please reach out to your Express Scripts account representative and DO NOT fill out this enrollment form.

Option 1 (Standard Product)

Standard COVID-19 OTC Test Kit Solution – for currently enrolled plan sponsors who want to maintain the benefit design as-is after the public health emergency expires.

Standard product specifications include1:

  • $12 per test ingredient cost
  • $0 dispensing fee
  • $0 per test member copay
  • 8 tests per member per 30-day period
  • Retail2 locations and Home Delivery included3
  • Direct Member Reimbursement (DMR)4: Members receive 100% reimbursement for in-network DMR claims and up to $12/test for out-of-network DMR claims
Option 2 (Customized Product), Effective May 12, 2023

Customized COVID-19 OTC Test Kit Solution – for currently enrolled plan sponsors who want to customize their benefit design with the below selections. Specifications not listed as customizable will follow the standard product offer in Option 1.

  • $0 per test member copay
  • Choose your desired number of tests per member per 30-day period:
    • 4, 6, or 8
  • Choose your desired Direct Member Reimbursement (DMR)4 design:
    • 100% reimbursement for in-network claims and a maximum of $12/test for out-of-network claims or
    • Use your existing prescription claim DMR design
  • Choose your desired claim channels for coverage:
    • Retail, Home Delivery, and DMR
    • Home Delivery only*

*This option is subject to State laws

Option 3 (New Enrollment), Effective May 12, 2023

COVID-19 OTC Test Kit Solution - enrollment for plan sponsors new to the program.

  • $12 per test ingredient cost
  • $0 dispensing fee
  • $0 per test member copay
  • Choose your desired number of tests per member per 30-day period:
    • 4, 6, or 8
  • Choose your desired Direct Member Reimbursement (DMR)4 design:
    • 100% reimbursement for in-network claims and a maximum of $12/test for out-of-network claims, or
    • Use your existing prescription claim DMR design
  • Choose your desired claim channels for coverage:
    • Retail, Home Delivery, and DMR
    • Home Delivery only*

*This option is subject to State laws

Option 4 (Withdraw Coverage), Effective May 12, 2023

If you’re currently enrolled but decide to stop offering OTC testing kits once the public health emergency expires, please choose Option 4. 

If we do not hear from you by March 28, 2023, coverage will continue with your current benefit design.

1. If you worked with your account team to customize your product upon enrollment in 2022, those changes will remain in place in 2023 when you select Option 1.
2. Retail = local retail pharmacies in your current pharmacy network
3. Home Delivery = kits shipped directly to members’ home from Express Scripts® Pharmacy
4. DMR = Direct Mail Reimbursement; member pays full cost of test out of pocket at a retail pharmacy location, then submits a claim for reimbursement

COVID-19 Over-the-Counter Test Kit Enrollment Form

Reminder: This enrollment can only be completed at the Carrier Level.

For sub-carrier level enrollment, please reach out to your Express Scripts account representative and do not fill out this enrollment form.
COVID-19 Over-the-Counter Test Kit Enrollment

Thank you
Thank you for submitting an enrollment update request for COVID-19 Over-the-Counter Test Kit coverage.

If you need to enroll more than one carrier, PLEASE READ CAREFULLY:
1. You should have received an email from Express Scripts for each carrier ID in your account.
2. Please use the link provided in each email, which will pre-populate the form with a new carrier ID.
3. If you did not receive multiple emails and still want to enroll more carriers, gather applicable Carrier ID numbers and reach out to your Express Scripts account representative for assistance.

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