Temporary Provisions to Waive Cost Sharing for COVID-19 Testing and Related Visits Ending May 11, 2023

Optima Health has continuously monitored the spread of COVID-19 to keep brokers, employers, and members informed of the latest developments and how these changes could affect their health plan.

Recently, the Department of Health and Human Services (HHS) announced that “although COVID-19 remains a public health priority, we are in a much better place in our response than we were three years ago, and we can transition away from the emergency phase.” The Administration is planning for the federal Public Health Emergency (PHE) for COVID-19 to expire at the end of the day on May 11, 2023.

What Does This Mean for Members?

The temporary provisions to waive cost sharing for COVID-19 vaccines, testing, and related services ordered by a physician or other provider, and over the counter tests (8 per member per month) are ending May 11, 2023, for individual and family plans, fully insured and BusinessEDGE® level-funded group plans. Please note the following about cost sharing for these services starting May 11, 2023:

COVID-19 over the counter (OTC) at-home test kits will continue to be covered as follows:

  • with prescription: covered under your plan pharmacy benefits at the tier 1 cost share and will be limited to four tests per month unless medically necessary
  • without a prescription: not covered

COVID-19 tests or related services during a physician visit:

  • will have the applicable cost share for the place of service

COVID-19 vaccines:

  • in-network: this is covered as a preventive health service and will continue to be $0 for all plan types
  • out-of-network: HMO will not be covered, PPO and POS will be covered at the applicable cost share

NOTE: Self-funded groups may decide if/when to waive cost sharing. Communications will be sent to impacted members over the next week to notify them of their new cost sharing.

For more information and ongoing updates, visit optimahealth.com/covid-19. Please contact your Optima Health representative if you have additional questions.