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 April 30, 2023. 

How can members order free at-home COVID-19 diagnostic test kits from Express Scripts?

Members who have their pharmacy benefits through their Medica plan can order up to eight at-home antigen COVID-19 test kits from Express Scripts, Medica’s pharmacy benefits administrator, for each member per month covered under a subscriber's plan. Members can sign in to Medica.com/SignIn, go to the Prescriptions section, select Go to your Express Scripts website and choose Order at-home COVID-19 tests.

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, 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 April 30, 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 inpatient treatment for COVID-19 covered?

We’ll waive copays, coinsurance, and deductibles for in-network COVID-19 inpatient hospital care for fully insured group members. Effective March 1, 2020, 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, 2023.

Is monoclonal antibody treatment covered?

COVID-19 monoclonal antibody treatment is covered with no member cost through April 30, 2023. Treatment must be medically necessary and ordered by an in-network medical professional. Coverage includes medications under emergency use authorization by the FDA including Eli Lilly (Bamianivimab and Bamlanivimab & Estesevimab) and Regeneron (Casirivimab and Imdevimab). Recommendations for these products are frequently changing. Speak with your provider about current treatment recommendations. 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, 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.

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.

How are durable medical equipment (DME) repairs or replacements of managed during the pandemic?

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.

What can you tell me about the vaccine for COVID-19?

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?

They include:

• 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.