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

BusinessEDGE® and Fully Insured Employers*:
Optima Health has continuously monitored the spread of COVID-19 to keep your employees 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 My Employees?

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 fully insured and BusinessEDGE® level-funded group plans. Please note the following about your 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

Communications will be sent to impacted members over the next week to notify them of their new cost sharing.

* If you are a large, self-funded group, please talk to your Optima Health representative to see how the public health emergency unwinding will impact your members.