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May 11, 2023

The federal government confirmed May 11, 2023, as the end of the COVID-19 public health emergency (PHE). Our Pharmacy Benefit Manager (PBM) Optum Rx has been planning for this change and reviewing recent guidance from the government agencies on how the end of the PHE affects COVID-19 vaccines, testing and treatments.

Provided below is a summary of Optum Rx’s standard approach for coverage when the PHE ends.  

  • COVID-19 vaccines: Cover Advisory Committee of Immunization Practices (ACIP) recommended, and Centers for Disease Control and Prevention (CDC) adopted COVID-19 vaccine and booster serum and administration when in network.  Applicable vaccine cost shares will apply for plans who have not elected the Optum Rx Health Care Reform Preventative Drug List.
  • Antivirals: Coverage for U.S. Federal Food and Drug Administration (FDA) approved or authorized COVID-19 treatments, including Paxlovid and molnupiravir (Lagevrio), in accordance with your plan benefits and applicable state law.
  • Over-the-counter (OTC) tests: No coverage of OTC COVID-19 tests for dates of service starting after May 11, 2023, with exception of any ASO clients that requested an extension.

The post-PHE standard approach accomplishes the following goals:

  • Supports return to normal plan benefits in a timely and consistent manner.
  • Aligns with commonly acceptable coverage for similar services .
  • Reduces variability and member confusion.

Further information on operationalizing these approaches, implementing a non-standard approach, and documenting your decisions related to coverage will be forthcoming.