RxBenefits and PBM Partners’ Response to COVID-19
Thursday, March 31, 2022
FDA authorizes a second COVID-19 booster dose for some
On Tuesday, March 29, the U.S. Food and Drug Administration (FDA) authorized a second booster of the COVID-19 vaccination for certain immunocompromised individuals, as well as people aged 50 and older.
In conjunction with the FDA’s authorization, the Centers for Disease Control and Prevention updated its recommendations to allow the administration of an additional booster dose.
Booster doses can be given four months after the initial booster. Specifically:
- People 50 and older can receive a second booster of either the Pfizer or Moderna vaccines four months after their initial booster
- A second booster dose of the Pfizer vaccine may be administered to immunocompromised individuals 12 years of age and older, four months after their initial booster of any authorized COVID-19 vaccine
- A second booster dose of the Moderna vaccine may be administered to immunocompromised individuals 18 years of age and older, four months after their initial booster of any authorized COVID-19 vaccine
For more information on the FDA authorization, please click here.
The list of medical conditions identifying immunocompromised individuals can be found on the CDC website; it includes cancer, kidney, lung, and liver disease, cystic fibrosis, diabetes, tuberculosis, and more.
Friday, January 21, 2022
COVID-19 Testing Update
RxBenefits is committed to keeping you informed as PBMs and private insurers respond to recent Biden administration guidance requiring insurers to reimburse members for over-the-counter, at-home COVID-19 tests. Here are the most current details, as of the time of this update:
- Private health insurance companies and groups will be required to reimburse members for up to eight tests per month per individual. Tests administered in a facility or ordered by prescription won’t count toward this total.
- Requirements for coverage apply to both grandfathered and non-grandfathered plans.
- No prescription, prior authorization, or requirement around attesting to COVID symptoms will be required for coverage.
- Members can expect $0.00 cost share until the PBM meets the safe harbor requirements by covering OTC tests at the point of sale and direct ship to members. Once safe harbor is met, out-of-network reimbursement can be capped at $12.00 or the cost of the test (whichever is lower).
- You can visit the USPS website to order 4 free home test kits, to be delivered to your residence.
RxBenefits will continue to keep an eye on the situation as PBM and federal government plans continue to evolve. Please watch this page for further updates, and reference the above links for information specific to each PBM.
Friday, January 14, 2021
COVID-19 Testing Update
On Monday, January 10, the Biden Administration announced that private health insurers must reimburse people for at-home COVID-19 tests in an effort to increase access to free testing. Beginning January 15, private health insurance companies and group plans will be required to pay for up to eight over-the-counter COVID-19 diagnostic tests per month per individual.
The guidance states that insurers and plans cannot limit coverage or reimbursement to tests purchased at preferred pharmacies and retailers. However, the guidance encourages insurers to set up programs through preferred networks to cover the cost of the tests upfront, so the member does not have to pay for the test themself and request reimbursement.
Due to the very fluid nature of this situation, RxBenefits will continue to monitor the situation and issue updates as the Federal Government and PBMs continue to solidify their plans. Please reference the above links for information specific to each PBM which will be continually updated as new information is received.
The U.S. Food and Drug Administration has authorized the use of a booster dose for each of the three major COVID-19 vaccines. Booster doses are authorized, but not required, for certain segments of the population:
- those 65 and older;
- those 18 and older who might be at high risk of severe COVID-19;
- those 18 and older who are frequently exposed to the virus, such as healthcare workers.
The FDA also approved heterologous, or “mix-and-match” boosters. That means people can get a booster shot of any of the three vaccines, even if they received a different vaccine initially.
NOTE: The initial doses of the two-shot vaccines (Moderna and Pfizer) are NOT mix-and-match. Only booster doses are heterologous.
Friday, August 21, 2020
Member reimbursements, appeal filing edit deadlines extended 180 days
On May 4, the U.S. Department of Labor (DOL) and the Internal Revenue Service (IRS) published new guidance that requires extensions on certain claim and appeal filing deadlines to allow additional time to make critical health coverage and other decisions affecting benefits during the COVID-19 pandemic. These extensions allow members additional time to file manual/paper claims and exercise their rights to appeal benefit and utilization review determinations.
- The DOL rule “Extension of Certain Timeframes for Employee Benefit Plans, Participants, and Beneficiaries Affected by the COVID-19 Outbreak” requires all benefit plans subject to ERISA or the Internal Revenue Code to disregard claimant claim and appeal filing deadlines under existing ERISA and Internal Revenue regulation for the duration of the “Outbreak Period.”
- The Outbreak Period began on March 1, 2020. It ends 60 days after the end of the COVID-19 national emergency, a date which has not yet been determined but will be announced later. This timeframe may end on different dates in different parts of the country, in which case additional guidance will be provided.
- The timeframe in which members may file a benefit claim under the plan’s claims procedure must be waived during the COVID-19 outbreak period.
- The timeframe in which members may file an appeal of an adverse benefit determination/denial must be waived during the COVID-19 outbreak period.
- The timeframe in which members may file a request for an external review after receipt of an adverse benefit determination or final internal adverse benefit determination is waived.
RxBenefits and the PBMs will be in compliance with the rule.
Wednesday, March 18, 2020
The world is grappling with an issue of enormous scale and human impact, and our hearts go out to all who have been or will be affected by the outbreak of coronavirus (COVID-19).
As your partner in health, we believe our role and responsibility is to prioritize three things:
- The health and well-being of our associates, partners, and clients,
- The provision of essential pharmacy benefit services, and
- Finally, playing a constructive role in supporting government officials and local communities as they endeavor to contain the virus and minimize the impact to the healthcare system.
We are committed to keeping you, our consulting partners, clients, and members, aware of all news related to the coronavirus (COVID-19). This is a rapidly evolving situation which we continue to monitor closely. As new information unfolds, we will keep you informed on any new details that impact your pharmacy benefits plan.
We are actively engaged with all of our PBM partners, and will continue to update you as new information is made available. If we have any news that is deemed urgent, we will email all clients with the information specific to their PBM choice. We will be making real-time updates as they come in throughout the day.
Together, we can help flatten the curve and slow the spread of the coronavirus (COVID-19).