Employer-based plan COVID-19 FAQs

How is COVID-19 testing covered?

We'll waive your copays, coinsurance and deductibles for medically necessary in-network COVID-19 diagnostic testing. This applies to testing that meets guidelines from Centers for Disease Control (CDC) and the Food and Drug Administration (FDA), and is ordered by an in-network medical professional. Testing isn't covered as part of a return-to-work requirement, public surveillance program, or travel requirement.

These changes are retroactive to March 1, 2020, and will extend through the public health emergency which is set to expire on May 11, 2023.

Are at-home OTC antigen COVID-19 diagnostic test kits covered?

Effective Jan. 15, 2022 through May 11, 2023, Medica members enrolled in individual plans and commercial fully and self-funded plans, and who have their pharmacy benefits through their Medica plan, have coverage for over-the-counter (OTC) FDA-authorized COVID-19 antigen tests without a prescription from a qualified health professional.

• Coverage includes up to eight FDA-approved OTC COVID-19 antigen home tests for each member per month covered under a subscriber's plan.
• Tests can be obtained through a network pharmacy or mail order at no cost using your Medica ID card.* Tests should be brought to the pharmacy counter to be submitted through the claims process.
• If you purchase the test through a retailer (e.g., at the front register), you will be charged the full cost of the test and will need to submit a claim form to be reimbursed. Reimbursement will be $12 per OTC test. Tests obtained at an out-of-network pharmacy or retailer are eligible for reimbursement at $12 per OTC test. Members will be required to submit a claim form to process reimbursement.
• OTC tests purchased prior to Jan. 15, 2022 are not eligible for reimbursement.
• Tests purchased to fulfill employer-directed testing requirements are not eligible for reimbursement.

*If you paid out-of-pocket for your OTC antigen tests, you will need to submit a request to get reimbursed for your costs.

To submit your reimbursement request online:

• Sign in to Medica.com/SignIn
• Go to the Prescriptions section and select Go to your Express Scripts website
• Click on Benefits and select Forms
• Go to Request reimbursement and click Start a Claim

To submit your reimbursement request by mail or fax:

Complete the Pharmacy Claim Submission form (Note: you don't need to enter the NCPDP/NPI information or have the form signed by the pharmacy)

• Mail your completed form and receipt(s) to:

Express Scripts
ATTN: Commercial Claims
P.O. Box. 14711
Lexington, KY 40512-4711

• Or fax your completed form and receipt(s) to 1-608-741-5475.

A listing of FDA-approved Emergency Use Authorization (EUA) COVID-19 antigen tests can be found on the FDA's website.

What is the difference between PCR and antigen COVID-19 diagnostic tests?

A PCR (or Polymerase Chain Reaction) test is used to detect genetic material from a specific organism, such as a virus. PCR tests detect viral RNA. PCR tests are sent to a lab for the assessment of the test. Results generally take a couple of days.

Antigen tests, also called rapid diagnostic tests, detect specific proteins on the surface of the coronavirus. Antigen tests can be purchased through a retailer and done at home. Results may come back in as little as 15 to 45 minutes.

Is antibody testing for COVID-19 covered?

Yes. We're covering the cost for FDA-approved antibody tests after a suspected (not confirmed) COVID-19 diagnosis. An in-network provider must order the tests, and they must be medically needed. Coverage will include office visits and other charges related to the antibody test when performed at in-network locations. They're not covered as part of a return-to-work requirement, public surveillance program, or travel requirement.

This coverage will extend through the public health emergency which is set to expire on May 11, 2023.

If I suspect I have COVID-19, how do I know if I'm eligible to get tested?

Call your primary care provider if you have a cough, fever, or shortness of breath to find out if you meet testing criteria.

If I suspect I have COVID-19, how do I find a clinic that can test me?

If your primary care provider recommends that you be tested, you may be sent directly to a testing center.

Is monoclonal antibody treatment covered?

Most COVID-19 monoclonal antibody treatments have been discontinued for use. FDA discontinued the Emergency Use Authorization (EUA) for nearly all of the drugs it previously approved. During the time when the EUA was in effect, Medica did provide coverage with no member cost when the treatment was medically necessary and ordered and received by an in-network medical professional. Some self-insured employers may not include antibody treatment coverage.

How are COVID-19 oral treatment drugs covered?

COVID-19 oral treatment drugs will be included in the preferred brand tier on Medica's Drug List. During the national public health emergency, which is set to expire on May 11, 2023, members will not be responsible for the ingredient cost of the COVID-19 oral treatment drug. Members will pay approximately $6 or their preferred brand copayment, whichever is less. After the national public health emergency ends, members will be responsible for their preferred brand copayment.

Are virtual care services available?

Yes. Virtual care, or telehealth, is a convenient way to get care for many common medical conditions by connecting with a provider from your computer or mobile device from home, work, or wherever you are. Although confirmation and testing of COVID-19 can't be done via virtual care, if you're experiencing symptoms, you can get help assessing risk and recommendations on next steps.

We expanded the availability of telehealth visits to include visits that:

• Are from your home
• Use technology such as FaceTime or Skype
• Use audio only when video is not available

To access virtual care:

• Check with your clinic to see if virtual care is available and learn how to connect with your provider online.
• Check other virtual care options that may be available in your plan's network at medica.com/FindADoctor. Click on Member through Employer, select their plan and click on Virtual Care Providers.