CVS/Caremark Response to Novel Coronavirus (COVID-19)

Updated 02.04.2022

Friday, February 04, 2022
OTC COVID Test Updates

Member Experience:

  • Neither a prescription nor prior authorization (PA) is required.
  • Each member is eligible for up to eight (8) over-the-counter (OTC) tests per month.
  • Point-of-sale (POS) and home delivery coverage available at participating pharmacies.
  • When Point-of-sale (POS) coverage is not available, members submit manual claims for reimbursement.
  • For claims assistance, contact RxBenefits Member Services

 Member Cost:

  • Member cost share is $0.00 at participating point-of-sale (POS) and home delivery pharmacies. Members pay applicable shipping costs.
  • Reimbursement for manual claims is capped at the lesser of the test cost or $12.00.

 Plan Cost:

  • Test kits purchased at participating point-of-sale (POS) and home delivery pharmacies adjudicate at usual and customary (U&C) rates.
  • Reimbursement for manual claims is capped at the lesser of the test cost or $12.00.
  • Standard billing cycle.

Tuesday, January 25, 2022
Latest Guidance About the OTC COVID Test

The Biden administration issued guidance recently requiring private health insurance companies to reimburse and cover members for up to eight (8) over-the-counter (OTC) COVID-19 tests per month.

Client Enrollment Process:

Clients will be automatically enrolled into Caremark’s COVID-19 Test Kit program. If a client wishes to opt out of coverage for COVID-19 test kits, please contact your dedicated Account Management team by January 26, 2022.

Member Details:

  • A written prescription or prior authorization is not required.
  • Each member is eligible for up to eight (8) OTC COVID-19 tests per month.
  • In Network: Point-of-sale (POS) claim processing and mail order coverage at participating network pharmacies.
  • Out of Network: Members must submit a claim form and a copy of their receipt for reimbursement.
  • Members can obtain test kits at any retailer. However, reimbursement for out of network pharmacies and retailers is capped at $12.
  • For assistance in filing claims, contact RxBenefits Member Services

Member Cost:

  • Shipping costs for mail order test kits.
  • In Network: $0.00 Point-of-sale (POS) and mail order
  • Out of Network: Reimbursement capped at $12.00

Plan Cost:

  • For OTC kits processed through the pharmacy benefit, CVS/Caremark will process payment of OTC COVID-19 test kits at market-competitive rates.
  • Standard contract terms apply for Point-of-sale (POS) and paper claims processing (Outlined in client contract)
  • Standard billing cycle.

Additional Resources

Friday, January 14, 2022
Important Information About the New OTC COVID Test Guidance

CVS Caremark® will utilize the carrier level coding applied to the COVID medications (antivirals) to quickly put in place a point-of-sale solution to include approved NDC’s according to Medispan starting 1/15/22. This will apply to all RxBenefits clients effective 1/15/22.

Point-of-sale (POS) Claims

  • Will not require a prescription
  • Limit will be 8 tests/member/30 days*

*If a member has a prescription that states >8/month, quantity limit will not apply

Paper Claims

  • Can be submitted via simplified claim form, with member attestation
  • Quantity limit will apply
  • Reimbursement may be higher than the $12 cap, max TBD

Wednesday, June 2, 2021
UPDATE: Effective on or after March 15, 2021, the Center for Medicare & Medicaid Services (CMS) updated the new Medicare FFS payment rate to approximately $40 for each dose. For single-dose COVID-19 vaccines, the Medicare payment rate will be approximately $40 for administration. For COVID-19 vaccines requiring multiple doses, the Medicare payment rate will be approximately $40 for each dose in the series. This rate reflects updated information about the costs involved in administering the COVID-19 vaccine for different types of providers and suppliers, and the additional resources necessary to ensure the vaccine is administered safely and appropriately.

CVS announced they would use the updated $40 / dose rate. However, a delay in coding deployment meant CVS processed vaccine claims from March 15 – April 16, 2021 with the prior rates. Due to pharmacy network obligations and client feedback, CVS will reprocess affected COVID-19 vaccine claims with the updated reimbursement rates. The reversal and reprocessing is used to adjudicate how the claims would have processed if the system had been coded with the updated rates at the time of fill.

As a result, in July clients may see updated claim activity with the current reimbursement rates for COVID-19 vaccine claims from March 15 – April 16.

Tuesday, March 23, 2021
Effective on or after March 15, 2021, the Center for Medicare & Medicaid Services (CMS) updated the new Medicare FFS payment rate to approximately $40 for each dose. For single-dose COVID-19 vaccines, the Medicare payment rate will be approximately $40 for administration. For COVID-19 vaccines requiring multiple doses, the Medicare payment rate will be approximately $40 for each dose in the series. This rate reflects updated information about the costs involved in administering the COVID-19 vaccine for different types of providers and suppliers, and the additional resources necessary to ensure the vaccine is administered safely and appropriately.

CVS has announced they would use the updated $40 / dose rate.

Tuesday, December 8, 2020
Important Announcement From CVS Caremark® Regarding Coverage of COVID-19 Vaccines

Pharmaceutical companies are expected to submit their COVID-19 vaccines to the U.S. Food and Drug Administration (FDA) for distribution under the Emergency Use Authorization (EUA) in the coming weeks. As they are approved, vaccines will be distributed in phases to prioritize initial populations including healthcare workers, front-line and essential workers, and people with an increased risk of severe illness from COVID-19.

During this initial phase, the federal government will purchase and allocate vaccines to states for prioritized distribution and will cover the ingredient cost of the COVID-19 vaccine. However, employers will be required to cover the administration costs, since most plans will require a $0 cost-share for their members.

What Does This Mean for RxBenefits Clients?
The COVID-19 vaccine will be covered by plans, but employers will need to pay an administrative cost for each dose. Most vaccine manufacturers require two doses of the vaccine. For example, the vaccine from Pfizer requires an initial dose and then a second dose 21 days later.

CVS Caremark® has aligned to the following reimbursement, that is in line with published rates from Medicare Fee-for-Service rates:

  • $16.94 to be reimbursed to pharmacies for the first COVID-19 vaccine dose
  • $28.39 will be reimbursed to pharmacies for the second dose for those COVID-19 vaccines requiring two doses
  • $28.39 will be reimbursed to pharmacies for COVID-19 vaccines requiring a single dose only

What Does This Mean for Members?
Members will be able to receive the COVID-19 vaccine for $0 cost-share once available.

Thursday, November 12, 2020
CVS Caremark Removing Quantity Limits for Chloroquine, Hydroxychloroquine Effective November 16, 2020

As shared in late March, CVS Caremark® implemented new quantity limits, on behalf of RxBenefits’ clients, for five specific medications to prevent potential stockpiling and inappropriate purchasing.

These medications included: chloroquine, hydroxychloroquine, azithromycin, Kaletra, and albuterol inhalers. When we made the initial announcement, we expressed the potential for changes based on changes to market dynamics, updates to prescribing protocols for the coronavirus disease 2019 (COVID-19), and utilization trends.

You will recall that:

  • Quantity limits for azithromycin were removed, effective June 1, 2020 and
  • Quantity limits for Kaletra were removed, effective August 1, 2020

Please be aware that the quantity limits for chloroquine and hydroxychloroquine are being removed effective November 16, 2020.

Ongoing evaluation of the use of chloroquine and hydroxychloroquine for the treatment of COVID-19 suggests utilization has stabilized near levels prior to the COVID-19 outbreak.  Additionally, CVS have not seen any significant changes in prescribing during this most recent outbreak. The quantity limits on albuterol remain. Utilization of albuterol inhalers continues to be above what was seen pre-COVID; therefore, we are continuing to monitor that utilization.

As noted back in March, as a part of this COVID-19 related strategy, this change will be automatically updated on behalf of RxBenefits clients, and no action is required by you.

CVS Caremark is committed to closely monitoring the marketplace as the COVID-19 epidemic continues. If market dynamics change, they will revisit the need for quantity limits.

Thursday, June 4, 2020
CVS Caremark COVID-19 Policy Update: Early Refill Limits to be Reinstated on June 15, 2020

In response to COVID-19, early refill restrictions were temporarily waived for all clients, helping ensure members had access to medications while sheltering in place to avoid the spread of COVID-19. With state governments beginning to ease guidelines and focusing on reopening the economy, plan member access to medical services and local pharmacies will increase. As this continues, some of the exceptions implemented due to the pandemic will not be needed.

Effective June 15, 2020, CVS Caremark will no longer waive early refill limits on 30-day prescriptions for maintenance medications. At that time, claims for maintenance medications will process in accordance with your standard refill thresholds, and the non-emergency refill threshold limits will again apply.

CVS Health pharmacies will continue to offer home delivery of maintenance medications to support social distancing standards.

Wednesday, March 25, 2020
CVS efforts to mitigate potential drug shortages and ensure patient access to medications during COVID-19 National Health Emergency

Given the quickly evolving national health emergency, we need to take action to help ensure your plan members have timely, safe access to medication. The steps being taken to help prevent stockpiling and gaps in therapy, including implementing quantity limits and extending prior authorizations, are outlined below.

Extending Prior Authorizations to Maintain Member Access

During this unprecedented time, it may be more challenging for members to see their prescribers – either because of decreased availability of appointments or personal concern overexposure. In order to prevent gaps in therapy, we are extending many clinical prior authorization records – set to expire between March 23 and June 30 – for 90 days. For instance, if a prior authorization is set to expire on May 15, the expiration date will be extended to August 15.

There are certain medications to which this will NOT apply: short term or one-time use medications, or related to opioid or hypnotic quantity limits

Preventing Potential Shortages of Key Drugs:

While there is no evidence at this time of widespread shortages, it is important to ensure that members with ongoing needs can maintain access to medications, while also enabling patients with COVID-19 to obtain treatment. Some of the medications being identified as possible treatments for COVID-19 are also used by members to treat existing conditions like HIV and lupus.

Beginning immediately, we are introducing a utilization management (UM) product bundle, which will institute quantity limits on medications that potentially treat COVID-19 and are used by members for other conditions.

Albuterol Meter Dose Inhalers:

  • A quantity limit will be added to albuterol inhalers, limiting them to two per 30 days (200 inhalations per device) at retail or six per 90 days at mail
    • These changes apply only to inhalers and not nebulizer solutions or oral tablets
    • These limits are already commonly used by many of our clients and included in some of our formulary designs

Chloroquine, hydroxychloroquine, Kaletra and azithromycin:

A quantity limit will be added to limit the supply dispensed of these drugs:

  • Chloroquine, hydroxychloroquine: 10-day supply, limit of one fill per 60 days
  • Kaletra: 14-day supply, limit of one fill per 60 days
  • Azithromycin 250 mg tablets, limit of 6 tablets or one blister pack of 6 tablets per five days; limit of one fill per 60 days
  • Members are limited to one fill of each product per 60 days

These limits will apply to claims from all pharmacies. While these medications may be useful in reducing the duration of COVID-19 and CVS wants to ensure appropriate member access for that purpose, it is important to ensure access for members using these medications to treat chronic conditions as well.

To minimize disruption for members currently taking these medications, CVS is implementing the following adjudication logic to identify diagnosis and previous utilization to bypass this limit:

  1. If a member has filled a 30-day supply within the previous 180 days, the claim will bypass the quantity limit.
  2. If the claim comes through with an appropriate non-COVID-19 diagnosis code, including lupus, rheumatoid arthritis (RA) or HIV, the claim will bypass the quantity limit.

If a member does not have: a claim history for these drugs OR a diagnosis code indicating lupus, RA or HIV, the quantity limit will apply. Prescriptions exceeding the quantity limits or with no diagnosis code will require prior authorization to confirm appropriate use.

Please note that there is no opportunity to opt-out of these enhancements at this time.

The situation is evolving rapidly as results from various clinical trials and case studies become available, and CVS will continue to evaluate the information and update the requirements as appropriate. Quantity limits and included medications will be automatically updated to stay in line with current clinical guidelines and marketplace conditions.

This is an uncertain time and we understand that your clients and your members are concerned about being able to obtain needed medications. We remain focused on ensuring plan members have timely, safe, and appropriate access to their medications – a service that’s more important now than ever.

Friday, March 13, 2020
CVS Health to Assist with COVID-19 Testing

Given CVS/Caremark’s physical presence in communities across the country and ability to reach millions of consumers with local solutions, they’re in a unique position to help address the COVID-19 pandemic. CVS Health is working with the administration and other partners to help facilitate COVID-19 testing with a common goal of increasing frequency and efficiency.

While details are still being worked out based on the number of tests available and geographic needs, it’s important for CVS Pharmacy customers to understand that they won’t be impacted. CVS expects testing will take place in secure areas of parking lots at select stores – not inside – and individuals being tested will not have to leave their cars. We will share more details as they become available.

Thursday, March 12, 2020
New CVS/Caremark Measures to Help Control the Spread of Coronavirus

Dear Valued Client:

As your partners in health, RxBenefits and CVS/Caremark are partnering to implement active measures to help you control the spread of the coronavirus (COVID-19). We are pleased to announce two new policies that will make it easier for members to access maintenance medications and keep an ample supply on hand, should they need to self-quarantine now or in the near future, per guidance from the CDC and other US health officials.

  1. CVS/Caremark is waiving early refill limits (refill too soon) on 30-day prescriptions for maintenance medications, at any in-network pharmacy
  2. CVS/Caremark and RxBenefits strongly recommend that all members take advantage of this waiver and refill all 30-day maintenance medications now
  3. CVS/Caremark will be waiving charges for home delivery of all prescription medications

Click here to view the full CVS/Caremark announcement.

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.

Please reach out to your account management team with any questions you may have.

Client Services | 866.769.5987

Member Services | 800.334.8134

Tuesday, March 10, 2020
Additional COVID-19 Resources to Increase Medication access to Medications

On March 9, 2020, CVS Health announced additional COVID-19 resources to increase patient access to medications.

Beginning immediately, CVS Pharmacy will waive charges for home delivery of prescription medications, which will help patients avoid visiting their local CVS Pharmacy for refills or new prescriptions.

CVS Caremark is working with all PBM clients to waive early refill limits on 30-day prescription maintenance medications.

Monday, March 9, 2020
Product & Medication Supply

CVS/Caremark is working with their suppliers to meet customer demand for products being sought in relation to the COVID-19 outbreak. This demand may cause temporary shortages for certain products at some store locations and CVS will re-supply those stores as quickly as possible.

CVS/Caremark is also closely monitoring the global manufacturing environment. They do not see any disruptions to the supply chain that will affect their ability to fill prescriptions for plan members, now and into the near future.

In addition, the Food and Drug Administration is closely monitoring medications that are made in China or rely solely on active pharmaceutical ingredients from China. The agency said it has reminded more than 180 manufacturers to notify the FDA of any potential supply chain disruptions.

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