COVID-19 Testing Changes: Coverage of Over-the-Counter (OTC) Tests Ended on May 12, 2023

During the Public Health Emergency, laboratory-based polymerase chain reaction (PCR) and over the counter (OTC) antigen tests were required to be covered without cost-sharing. The Health Plan was also required to cover eight free OTC tests per month, with a $12 limit per test. As of May 12, 2023, the Health Plan only covers COVID-19 tests in accordance with both Cigna’s and Optum RX’s standard policies:

Now the Health Plan only covers COVID-19 tests in accordance with both Cigna’s and Optum RX’s standard policies:

  • Cigna Medical Plan – OTC test kits are no longer covered under the Cigna medical plan. PCR tests continue to be covered under the medical benefit for both Tiers based on the standard lab benefit provisions for that Tier (which may be different for in and out-of-network coverage).
  • Optum RX Plan – OTC test kits are no longer covered under the Optum RX plan.

COVID-19 Vaccine Coverage: Vaccines Obtained Through the Cigna Medical Plan or Optum RX Plan Are Now Covered

During the Public Health Emergency, the Fund covered COVID-19 vaccines at no cost to the participant, through both the Cigna medical plan and the Optum prescription drug plan, for all Tiers.

Currently, the Fund’s two Tiers continue to cover COVID-19 vaccines at no cost, but only when obtained from an in-network provider through the CIGNA medical plan – which would also include retail pharmacies that are in-network with Cigna. Coverage for vaccines obtained from an out-of-network medical provider is based on the rules for your Tier of coverage. The Fund also covers vaccines obtained at a pharmacy with Optum RX for both Tiers.

For a complete list of in-network providers, including locating retail pharmacies under the Cigna Plan, please visit www.mycigna.com. To locate an in-network pharmacy with Optum RX, visit www.optumrx.com.

COVID-19 Antiviral Medication Treatment Changes for the Optum RX Plan

Since 2022, the Federal Government provided COVID-19 antiviral prescription drugs at no cost; this supply is expected to run out sometime in 2024. This medication is currently only being administered under the Optum RX benefit and is not available under the Cigna medical plan. Optum RX will continue covering this medication at 100% (meaning no cost to you) as long as supplies from the Federal Government last. After that supply of drugs from the Federal Government has been exhausted, the Health Plan will charge a co-payment of 30% of the cost of the medication under all 3 Tiers. This medication will fall into Optum RX’s expected Non-Preferred/Non-Formulary drug class category, with a quantity limit of 1 treatment course per fill and up to 2 courses permitted per year. There is a possibility that Optum RX could place this drug class in a different category in the near future in which the out-of-pocket copayment cost would eventually become cheaper.

Here are two charts that summarizes how each of the benefit items will be covered under either the Cigna Medical/Optum RX Plans beginning May 12, 2023:

Cigna Medical Plan

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Lab Tests (PCR)
OTC Test Kits
COVID-19 Vaccine
COVID-19 Antiviral Medication
Tier 1 – In Network
Plan pays 100%
Not covered
Plan pays 100%
Not covered – covered under the Optum RX plan. See chart below
Tier 1 Out-of-Network*
Plan pays 70% of reasonable and Customary charges after deductible has been satisfied
Not covered
Plan pays 70% of reasonable and Customary charges after deductible has been satisfied
Not covered – covered under the Optum RX plan. See chart below
Tier 2 In-Network
Plan pays 100%
Not covered
Plan pays 100%
Not covered – covered under the Optum RX plan. See chart below
Tier 2 Out-of-Network**
Plan pays 70% of reasonable and Customary charges after deductible has been satisfied
Not covered
Plan pays 70% of reasonable and Customary charges after deductible has been satisfied
Not covered – covered under the Optum RX plan. See chart below

*Tier 1 calendar year (January 1-December 31) deductible is $500 for an individual and $1,000 for a family. Once an out-of-pocket maximum limit of $7,000 for an individual, and $14,000 for family coverage, has been met, the Plan will pay 100% of Reasonable and Customary charges.

**Tier 2 calendar year (January1-December 31) deductible is $4,000 for an individual and $8,000 for a family. Once an out-of-pocket maximum limit of $8,000 for an individual, and $16,000 for family coverage, has been met, the Plan will pay 100% of Reasonable and Customary charges.

Optum RX Plan

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Lab Tests (PCR)
OTC Test Kits
COVID-19 Vaccine
COVID-19 Antiviral Medication
Tier 1 – In Network at a Retail Pharmacy****
Not covered
Not covered
Plan pays 100%
Plan pays 100% while the government supply is available. Once the supply ends, 30% coinsurance of the cost of the drug with a minimum copay requirement of $25 will be required.
Tier 2 In-Network Only at a Retain Pharmacy*****
Not covered
Not covered
Plan pays 100%
Plan pays 100% while the government supply is available. Once the supply ends, 30% coinsurance of the cost of the drug with a minimum copay requirement of $60 will be required.
Tier 2 In-Network Only at a Retain Pharmacy*****
Not covered
Not covered
Plan pays 100%
Plan pays 100% while the government supply is available. Once the supply ends, 30% coinsurance of the cost of the drug with a minimum copay requirement of $60 will be required.

****Tier 1 calendar year (January 1-December 31) deductible is $100 for an individual and $200 for a family.

*****Tier 2 calendar year (January 1-December 31) deductible is $100 for an individual and $200 for a family. Also, you must use an in-network pharmacy for Tier 2. There is no out-of-network drug coverage.

The annual out-of-pocket maximum limits for covered prescription drugs for both Tiers combined is $4,000 per individual, $8,000 per family each calendar year (January1-December 31). Once these limits have been met, the Plan will pay 100% of the cost of the medication.

If you have medical coverage through an HMO Plan, please check with your HMO provider as to how they will be covering these specific benefit items beginning May 12, 2023. Details can also be located online with your applicable HMO provider. For Emblem Health – HIP NY, visit, www.emblemhealth.com. For any of the Kaiser HMO plans, please visit www.kaiserpermanente.org.