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Employer-based plan COVID-19 FAQs
Get answers to common questions about Employer-based plans and COVID-19. Find out about prevention, testing, treatment, vaccinations, coverage, and more.
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 April 30, 2022.
Are at-home OTC antigen COVID-19 diagnostic test kits covered?
Effective Jan. 15, 2022, and for the duration of the national public health emergency, Medica members enrolled in individual plans and commercial fully and self-funded plans 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 can complete and submit a Pharmacy Claim Submission form (Note: you don’t need to enter the NCPD/NPI or have the form signed by the pharmacy).
Completed forms and receipt(s) can be submitted at Medica.com/SignIn, or mailed to the following address for reimbursement:
ATTN: Commercial Claims
P.O. Box. 14711
Lexington, KY 40512-4711
Or you can fax your claim 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 April 30, 2022.
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.
We’ll waive copays, coinsurance, and deductibles for in-network COVID-19 inpatient hospital care for fully insured group members. These changes are retroactive to March 1, 2020, and will extend through September 30, 2021.
If you’re enrolled through a self-funded employer-sponsored plan, please check with your employer, since coverage may be different. You can also call our Customer Service department at the number on the back of your Medica ID card for details.
Will prior authorization requirements for care requests be waived?
Yes. Prior authorization isn’t required for admissions to long-term care facilities, acute inpatient rehabilitation, and skilled nursing and home health care facilities. This change is in effect through April 30, 2022.
Will early refills for prescriptions be authorized?
Maybe. If you have prescription benefits with us, and your medication needs to be filled early, submit your refill request to your pharmacy. They will determine if your prescription can be filled early.
Can I get a 90-day supply of my prescription medication(s)?
Yes. Members can continue to request a 90-day supply of long-term medications used to treat chronic conditions. At this time, we won’t authorize requests to fill medications that aren’t eligible for 90-day refills.
Your options include:
1. Home Delivery (mail order) Prescription Services*
Mail-order home delivery of your prescriptions is available with most of our plans. Some home delivery requests may require an in-person office visit and a new prescription from a prescriber. To learn more and request mail order delivery of your medications, sign in to your account.
2. Retail pharmacy home delivery
Many retail pharmacies will mail your prescription to your home, free of charge. Check with your pharmacy for details.
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.
From now through April 30, 2022, for all fully and self-insured groups, repairing or replacing DME doesn’t require a new physician’s order, face-to-face visit, or medical necessity documentation. But these items are still needed for new DME requests. This change is consistent with the Centers for Medicare & Medicaid Services guidelines to help all patients get the care they need during the pandemic.
Get answers to frequently asked questions about COVID-19 vaccine coverage and availability in this PDF.
What options do I have if I lose my group plan coverage?
- Continue on employer’s plan through Continuation/COBRA
- Enroll in an individual plan through an insurance carrier like Medica
- Enroll in a Medicare plan through an insurance carrier like Medica (if you’re eligible for Medicare)
Learn more about Continuing Your Health Insurance options
For Medica Individual and Family coverage options, call 1-800-670-5935.