FAQs for Employers and Producers – Fully insured plans

Updated September 25, 2023

We recognize the challenges COVID-19 and associated state and federal mandates regarding business operations pose to you, your employees, and your business. Our top priority is supporting employees’ access to vaccines, connecting them to care and supporting you, our valued business partners, during this evolving crisis.

The following information is a compilation of the most frequent questions we have received to date. We have attempted to provide responses that apply in the broadest sense. As always, your account executive is available to answer questions specific to your plan.

Frequently asked questions

Member support FAQ
 What steps have we taken to support our members?

The health of our members is our top priority. Read the latest actions we’re taking to support our members.

  • No-cost COVID-19 vaccinations, including booster shots for those who are authorized by the CDC to receive them. The federal government is paying for enough vaccine doses to immunize every American during the course of the pandemic. Administrative fees will be covered by most health plans. Legacy and retiree only plans are not required to cover administration without cost-sharing.

  • No-cost coverage and no pre-authorization requirement for COVID-19 treatment by in-network providers through 6/30/22 in Idaho.

  • No-cost coverage for COVID-19 testing when done for diagnostic purposes, meaning when a member has symptoms or has been in close contact with an infected person. This includes up to eight (8) over-the-counter at-home rapid tests per member each month without a provider’s order, and an unlimited number of tests when ordered by a member’s provider as part of appropriate medical care.

  • As with drug testing for employment, health insurance does not cover COVID-19 testing for employment, surveillance, tracking or extracurricular activities, such as travel, school, sports or summer camps.

Enhanced support for high-risk members

  • We’re in contact with high-risk members using our case management services to ensure they have the support they need.

  • As we learn of members hospitalized with the virus, we are reaching out to provide personalized support.

  • We’re moving members on infused medications from hospital to home settings or infusion centers.

Access to needed medications

  • Members may receive early refills of most medications through the end of the declaration of emergency in the state where their plan is issued, so they have enough on hand.

  • Members can request a 90-day refill of medications for chronic conditions such as heart disease, asthma, diabetes and others. Some drugs are not eligible for extended day supply, including controlled substances and certain specialty drugs (ineligible drugs are those in the “Narcotics” section or marked “SP” on our drug lists).

  • Members with prescription coverage through Regence can order home-delivery prescriptions through the Express Scripts website.

Enhancing coverage for virtual care

To help slow the spread of infection and ease pressure on providers’ offices and emergency rooms, we’ve enhanced coverage for virtual care:

  • Members have access to telehealth vendors that provide services such as video visits and secure messaging with doctors and nurses, and home health visits in select areas. These options may differ by employer, and employers can consult their summary of benefits coverage (SBC) for their specific telehealth offering. Employees should sign-in or create an account on regence.com, or download the Regence app, to learn about the virtual care options included in their plan. A flyer and video on regence.com contain all the instructions for doing this; be sure all employees have access to these instructions.

  • We’ve expanded the services that can be delivered by providers using virtual care options.

  • Members’ own providers, including PCPs, behavioral health specialists, and others, may also have virtual care options. If members don’t have a doctor or therapist, they should call Customer Service for help finding one.

Expanding resources for self-care

To help members address a wide range of emotional and physical health needs, we’ve broadened access to three useful tools:

  • Active&Fit – members have free access to 200 on-demand digital workout videos and daily live workouts from Active&Fit. Enrollment in Active&Fit is not required; Regence members need only to access the Active&Fit website from their Regence account page and register there to receive access to the workout videos.

  • Regence Empower – provides members tips for staying healthy, what to do when sick, and advice to help slow the spread of the disease. Includes self-guided programs for managing stress, enhancing physical activity, and building resilience, along with personal challenges supporting sleep, nutrition, physical activity, and social and emotional well-being.

  • Symptom Checker – offers members timely guidance and support to help them determine whether medical attention is needed. Not intended to replace a clinical assessment or the judgment of health care professionals.
Eligibility FAQ
 Our company laid off or furloughed staff. Can we keep them covered under our Regence plan?

Groups may use the standard leave of absence guidelines up to three months for employees for any acceptable reason by the group, including for a reduction of hours. Leave of absence is at the employer's discretion and is managed by the employer.

 What happens at the end of the three-month leave of absence?

At the end of three months, employees need to return to an active, at-work status, or terminate from the plan. Options for coverage may include state continuation of coverage, FMLA, COBRA or state exchanges.

We will look to the client to monitor eligibility that is passed to our systems. Temporarily employees can maintain their coverage on their Regence plans as long as the reduction in hours/layoff is a temporary measure resulting from COVID-19, the group continues to pay premiums and the employees are not terminated.

 If we terminate someone’s employment because their hours have been reduced, can we waive the waiting period when they return to working 30+ hours?

Yes, if the employee is recalled within three months of termination and had previously satisfied the waiting period.

 If a furloughed employee can no longer afford their coverage, can they drop their coverage without a qualifying event?

Yes. They can return to the plan within three months. If the employee maintains their Regence member ID #, their out-of-pocket accumulators will be carried forward.

 Can we adjust hours to keep employees on the health plan?

Employers up to 100 employees may temporarily self-administer hours of eligibility to the contract minimums without prior approval. Minimums are established by states as follows:

  • Idaho – 20 hours
  • Oregon – 17.5 hours (no state minimum, market standard)
  • Utah – 30 hours
  • Washington – 20 hours (no state minimum, market standard)
 Can we reduce our contribution to premiums to keep employees covered?

Yes, to 50 percent of the lowest-cost health plan offered to your employees. The employee contribution would increase to cover the full premium.

Plans & benefits FAQ
 Can we keep our insurance plan if we’re required to temporarily close?

Yes, as long as there is active enrollment on the plan. If all employees are terminated from a plan, the contract will be cancelled and you would need to reapply for coverage.

 Can we have a special COVID-19 open enrollment period to allow employees who waived earlier on the plan to enroll?

We are not offering special COVID-19 enrollment at this time. Some state-based exchanges are offering a special enrollment period for individual participants.

 Can we change plans (for a lower premium plan) midyear?

Yes. Groups with fewer than 50 employees would need to establish a new 12-month contract by completing a renewal GMA. During that process, they can select lower benefits, a different contribution amount, and different eligibility guidelines. Groups 51+ should contact their account executive to determine the options that best fit their needs. For groups with 50 or fewer employees, a renewal GMA is required.

 If we offer multiple plans, will we allow our employees to downgrade benefits midyear?

Small employers may with underwriting approval change benefits off anniversary. This requires a new contract, including rates and current mandated benefits. If employers make a mid-year contract change, employees may then select a new plan and enroll (if eligible) or disenroll in coverage.

Mid-size (51-100) employers may with underwriting approval make a mid-year benefit buy down. Underwriting and sales will map enrollment from one plan to the other and no additional enrollment changes will be allowed. Employees may not voluntarily change plan elections outside of a contract re-write or their scheduled open enrollment.

 Will Regence extend premium grace periods for fully insured customers from 30 to 60 days?

Premium grace periods are state specific and comply with emergency orders:

  • Idaho – 30 days
  • Oregon – 60 days
  • Utah – 30 days
  • Washington – 30 days
 How is Regence covering COVID-19 vaccinations, testing and treatment?

We are covering COVID-19 vaccinations, antigen and molecular diagnostic testing (and the associated office visit) during the state of emergency, and treatment at no cost share to the member into 2021. Testing must be ordered by a medical professional. We also cover COVID-19 antibody tests at no member cost share when ordered by a member’s attending physician and part of appropriate medical care. COVID-19 tests must be performed at a CLIA-certified lab, or the test manufacturer must have FDA Emergency Use Authorization. As with other tests for employment, such as drug tests, antibody tests for employment purposes are not covered by insurance.

 What behavioral health options are available to our employees?

Your health plan may include an Employee Assistance Plan (EAP) benefit. Telehealth vendors also provide behavioral health services. In addition, members’ regular providers may be able to offer telehealth services through our temporary expanded virtual care services.

 Can we add a telehealth vendor to our plan?

Yes, you can add Doctor on Demand. Call your account executive to learn more.

 What does the expanded telehealth policy cover?

To help prevent the spread of infection and ease pressure on doctor’s offices, urgent care centers and emergency rooms, we have temporarily expanded the services available through our telehealth benefit. Any contracted provider may now offer virtual care services, even on a non-HIPAA-compliant platform. This includes routine preventive appointments with members’ primary care doctors and behavioral health providers. This expansion remains in effect into 2021. The member’s coinsurance and deductible will apply to these services.

 How is Regence complying with the DOL guidance on COBRA deadlines?

This rule applies to ERISA groups only. COBRA remains an employer-specific responsibility. The following represents our understanding at this point in time.

The DOL, IRS and HHS guidance under the EBSA Disaster Relief Notice 2020-01 extends certain COBRA timeframes and deadlines for participants to consider coverage elections and benefits decisions.

Specifically, Final Rule provides plan participants, beneficiaries, qualified beneficiaries, and claimants with relief from meeting the below referenced periods and dates during the period of March 1, 2020 until 60 days after the announced end of the COVID-19 National Emergency (or such other date announced by the Agencies in a future notice):

  • The 30-day period (or 60-day period, if applicable) to request a special enrollment;
  • The 60-day election period for COBRA continuation coverage;
  • The date/deadline for making COBRA premium payments;
  • The deadline for individuals to notify the plan of a qualifying event or determination of disability;
  • The deadline within which employees can file a benefit claim, or a claimant can appeal an adverse benefit determination, under a group health plan’s or disability plan’s claims procedures;
Vaccines FAQ
 Which COVID-19 vaccines are covered?

All vaccines that have received approval or emergency use authorization from the U.S. Food and Drug Administration (FDA) for public distribution are covered. These include the Pfizer-BioNTech (now called Comirnaty), Moderna and Johnson & Johnson vaccines. The federal government is paying for enough vaccine for every American to be vaccinated during the course of the pandemic.

Vaccine administration is covered at no out-of-pocket cost for Medicare, fully insured and most ASO members. Legacy and retiree only plans are not required to cover administration without cost-sharing. However, we have chosen to cover the administrative fee for fully insured legacy plans without cost-sharing.

Balance billing is not permitted. From the Centers for Disease Control and Prevention (CDC): “Providers that participate in the CDC COVID-19 Vaccination Program contractually agree to administer a COVID-19 vaccine regardless of an individual’s ability to pay and regardless of their coverage status, and also may not seek any reimbursement, including through balance billing, from a vaccine recipient.”

 When can members get a COVID-19 vaccine?

COVID-19 vaccines are available to all members 5 and older. The FDA has approved the two-dose Pfizer-BioNTech vaccine (now called Comirnaty) for people 18 and older, and Emergency Use Authorization (EUA) for people 5-17 years of age. In addition, the FDA has approved EUA for the one-dose Janssen (Johnson & Johnson) and two-dose Moderna vaccines for people 18 and older.

People who receive the two-dose Comirnaty and Moderna vaccines should have their two doses administered three weeks apart.

 When can members get COVID-19 booster shots?

The CDC has authorized and recommends COVID-19 booster shots for all people 12 and older under the following conditions:

  • Members 12 and older at least five months after receiving their primary two doses of the Comirnaty (Pfizer-BioNTech) vaccine
  • Members 18 and older at least six months after receiving their primary two doses of Moderna vaccines
  • Members 18 and older at least two months after receiving their primary dose of the Janssen (Johnson & Johnson) vaccine

The CDC also authorized use of a "mix and match" booster dose. People may choose a single dose of any available COVID-19 vaccine as a booster after they are fully vaccinated. People should speak with their provider about which vaccine booster is right for them. People are considered fully vaccinated two weeks after receiving the single shot of the Johnson & Johnson vaccine or the second shot of Pfizer or Moderna vaccines.

 Where can members get a COVID-19 vaccine?

COVID-19 vaccines are widely available through healthcare providers and pharmacies everywhere in the U.S. Employers with Regence health plans can host an onsite vaccination clinic, providing COVID-19, influenza, tetanus, hepatitis and other routine vaccinations with no out-of-pocket costs to employees and covered dependents. Click on your state name below for more information about employer onsite vaccination clinics.

Each state’s health department will have specific information about vaccine prioritization and distribution.

 What are we doing to support COVID-19 vaccinations in the community?

We are working to encourage all members to work with their medical provider to get vaccinated. Regence is working with our community partners, public officials and others to ensure that underserved communities and people of color – groups that have been disproportionally affected by the pandemic – are vaccinated.

 Where can people go for more information?

Members should check their state’s health department website or call their doctor or pharmacist to schedule an appointment to receive the vaccine.

The CDC provides these resources to learn more about the COVID-19 vaccine:


 Who pays for the vaccine?

The vaccine itself doesn’t cost consumers anything regardless of insurance coverage. The federal government has bought enough vaccine doses to immunize every American. The Centers for Medicare and Medicaid Services (CMS) or private insurance pays for the administration of the vaccine. Older legacy plans may pass administration costs on to their members.

 What is the anticipated impact of COVID-19 on health plan premiums?

It is too early to tell if COVID-19 will have an impact on future premiums.

 What is the difference in cost between the COVID-19 vaccines vs. the flu shot?

The administrative fee for the flu vaccine is around $7 versus the fee for administering the COVID-19 vaccine, which is currently around $45. In addition to the administrative fee, vaccine costs will vary based on manufacturer pricing. At present, all drug costs for COVID-19 vaccines are being covered by the government.

 What is the status on vaccine options, including efficacy rates and FDA approval of each (including those in the pipeline)?

We follow the New York Times vaccine tracker for the latest on vaccines and suggest you do too.

  How do we determine eligibility and the timeline for vaccination scheduling?

For the most accurate and up-to-date information on vaccine eligibility, prioritization and distribution, the best source is your state’s public health department website:

 What steps should be taken to ensure that everyone understands the importance of being vaccinated?

Lead by example. Everyone can contribute to community health by:

  • Getting fully vaccinated and keeping your vaccine status up to date. The CDC defines fully vaccinated as a person having received their primary series of COVID-19 vaccines. The CDC defines up to date as a person having received all recommended COVID-19 vaccines, including any booster dose(s) when eligible. This guidance is updated periodically so please visit www.CDC.gov for the latest.
  • Recognizing that while getting vaccinated helps provide protection against moderate to severe illness, hospitalization and death, it doesn’t provide 100% immunity from getting COVID-19 and transmitting it to others.
  • Practicing the three Ws: wear a mask when in public, wash hands frequently, watch your distance from those outside your household.
  • Quarantining at the first sign of possible infection symptoms or when exposed to someone who is known to be infected.
  • Stopping the spread of misinformation. Check your information sources before sharing information about the pandemic with anyone. When in doubt, rely on your state health department, the FDA or the CDC.

Safety & Efficacy

 What is the length of efficacy for the various COVID-19 vaccines?

There is evidence that vaccine efficacy begins to wane after several months, and medical experts are learning more about vaccine efficacy as more time passes since the first eligible recipients were vaccinated in late 2020 and early 2021. The CDC strongly recommends COVID-19 booster shots under the following conditions:

  • People 12 and older, at least five months after receiving their primary two doses of the Comirnaty (Pfizer-BioNTech) vaccine
  • People 18 and older, at least six months after receiving their primary two doses of the Moderna vaccines
  • People 18 and older, at least two months after receiving their primary dose of the Janssen (Johnson & Johnson) vaccine

The CDC will be your best source of information about vaccines for COVID-19.

 Do we have a choice of vaccine, and which is best?

Medical experts advise getting whichever vaccine is available to you. They all protect against serious illness and death.

 Is it a live vaccine? Does it provide immunity, or just protect against severity?

The current vaccines do not contain the coronavirus or inactivated virus. NPR offers a great explanation on what vaccine efficacy means. Getting vaccinated can reduce the chance of getting COVID-19. If you still get infected and experience symptoms, the vaccine can help protect you against serious illness, hospitalization and death.

 How can we trust the clinical trials – were they done for long enough?

Vaccines are developed by teams of world-class scientists with many years of education and experience. All vaccines undergo extensive trials to prove safety and effectiveness, involving tens of thousands of people who volunteer to receive the vaccine. The FDA grants emergency use authorization (EUA) only when independent analyses confirm a vaccine is safe and effective. Full approval is granted when, over time, the FDA has amassed even more scientific evidence to support use of the COVID-19 vaccines, showing that the benefits of the vaccine are greater than its risks, and that the vaccines can be manufactured reliably, safely and with consistent quality.

The Pfizer-BioNTech (Comirnaty) and Moderna vaccines have an effectiveness rate of more than 95% in adults. While these vaccines were developed in 2020, the technology behind them has been studied for years. The vaccines do not contain the virus or inactivated virus. You cannot get COVID-19 from the COVID-19 vaccines.

Comirnaty has received full FDA approval for people 18 and older, and EUA for people 5 to 17 years of age. COVID-19 vaccines manufactured by Johnson & Johnson (also known as Janssen Biotech, a pharmaceutical company of J&J) and Moderna vaccines have received EUA for people 18 and older.

We recommend reviewing the New York Times vaccine tracker for further explanation of how vaccines are developed and what phase COVID-19 vaccines are currently in.

 Regarding the Pfizer-BioNTech (Comirnaty) and Moderna vaccines; does your second dose have to be the same type as the first?

The federal agencies authorized use of a "mix and match" booster dose. People may choose a single dose of any available COVID-19 vaccine as a booster after they are fully vaccinated. People should speak with their provider about which vaccine booster is right for them.

 Are the current vaccines effective against the new strains? Are they being tested and/or modified to respond?

The current vaccines help provide protection against moderate to severe illness, hospitalization and death. The emergence and transmission of new virus strains is highly dynamic, and we suggest referring to the CDC for the most current information.

 What are the short-term side effects of the vaccines?

The majority of people will experience no side effects other than a sore arm. About 10% may have flu like symptoms for a couple of days as the body develops antibodies. This is normal and generally not cause for alarm. Providers typically require vaccine recipients to wait for a 15 to 30-minute observation period just to be safe.

 What are the long-term side effects of the vaccines?

The CDC says that serious side effects that could cause a long-term health problem are extremely unlikely following any vaccination, including COVID-19 vaccination. The CDC offers comprehensive information about vaccine safety and monitoring.

 Once a person is vaccinated, can they still transmit the virus?

Yes. Fully vaccinated people can still contract the coronavirus that causes COVID-19, and spread it to other vaccinated and unvaccinated people. As with the unvaccinated, a vaccinated person can contract the coronavirus and experience a range of symptoms. In rare cases, a vaccinated person who contracts COVID-19 can experience moderate to severe symptoms requiring hospitalization.

Even after receiving a vaccination, safety protocols including masking, distancing, washing hands frequently, and quarantining if symptoms or exposure to a known infected person occur are all strongly recommended to help prevent the spread of COVID.

 Do the vaccines change your DNA? Or cause a gene mutation in humans?


 Is J&J also an mRNA vaccine?

No. J & J is not a mRNA vaccine but a vector-based vaccine using a modified adenovirus using a double stranded DNA to cause the host cell to produce mRNA and spike proteins resulting in an immune response (antibodies) ready to attack a COVID-19 virus. For more information, read: How the Johnson & Johnson Covid-19 Vaccine Works - The New York Times (nytimes.com)

 Is it true that there are nanoparticles contained within these injectable technologies?

Yes. The Novavax is an example of such a vaccine technology. See How the Novavax Covid-19 Vaccine Works - The New York Times (nytimes.com) for more information.

 Is there anyone who shouldn’t get the vaccine?

Some immunocompromised individuals should not get a COVID-19 vaccination. Please consult with your doctor if you have any questions about getting vaccinated, whether related to allergies, pregnancy, or other medical or health conditions.

 What alternatives are available outside of taking these vaccines?

Medical evidence shows that getting a COVID-19 vaccination can help keep you, your family, your community, and your country healthy and safe. Getting vaccinated can greatly reduce your chances of experiencing moderate to severe illness and death should you contract the coronavirus.

Available COVID-19 vaccines have undergone rigorous clinical trials to prove safety and effectiveness before they receive permission from the FDA for broad distribution. Clinical trials involve tens of thousands of people who volunteer to receive the vaccine. The FDA grants emergency use authorization only if independent analysis confirms the vaccines are safe and effective.

 What about the use of Ivermectin?

Regence health plans cover FDA-approved treatment for COVID-19. Ivermectin is not approved for the prevention or treatment of COVID-19. There is no clinical evidence supporting the efficacy of Ivermectin for treatment of COVID-19 symptoms.

After the vaccination

 Is it still necessary to wear a mask after receiving the vaccine?

Yes, the CDC has issued guidance recommending continued mask wearing, physical distancing and frequent handwashing when in public places. Many states have reinstituted public mask wearing mandates since the most recent COVID-19 surge, fueled by the Delta variant, began. In addition, quarantining immediately when symptoms or exposure to an infected person occur is also strongly recommended.

It takes a few weeks for your body to build up immunity after vaccination. In addition, while the vaccines have a high efficacy rate for preventing serious illness and death, a vaccinated person may still be susceptible to getting the virus and transmitting it to others.

Check with your state or local health department on additional safety protocols for your community.

 How long will it be before there’s no more need for masks and social distancing?

That really depends on us. If we get vaccinated, get booster shots, continue to mask up, maintain physical distance, wash hands frequently, and quarantine at the first occurrence of symptoms or exposure to a known infected person, we can help stop the virus from spreading. Your state and local health departments will be your best source of information about community safety protocol.

 What are the metrics and anticipated timeline for herd immunity from COVID-19?

Medical experts do not know for sure. Herd immunity occurs when the vast majority of a population is immune from an infection. For highly infectious viruses such as measles, herd immunity occurs when 92 – 94% of the population is immune. At 70 – 80% herd immunity, we would start to see a reduction in case rates. The CDC will be your best source of information about herd immunity for COVID-19.

 I’ve heard that people that have survived COVID-19 feel they have protection and may not need a vaccine. Can you address this?

It is unknown how long natural immunity lasts. Reinfection with COVID-19 is common, and often with more severe symptoms than the initial infection. If it’s been more than 90 days since you’ve had COVID-19, medical experts recommend getting vaccinated.


 Are there any opportunities for onsite vaccination clinics? (like with the flu shot)

Yes. Employers can begin scheduling onsite vaccination clinics. Many onsite vaccination clinic providers offer COVID-19 and flu shots. And, to help employees catch up on other routine annual vaccinations, many providers also offer shots for hepatitis, pneumonia, shingles, tetanus, and more. Employers should contact their Regence account representative for more information about how to schedule an onsite vaccination clinic.

 Is COVID-19 testing for the purposes of employment covered by insurance?

No. Testing for the purposes of employment is not covered by insurance, and employers are not required to pay for testing of employees. Please see the Testing FAQ tab for more information about COVID-19 testing coverage.

 How can we encourage or incentivize our employees to get the vaccine?

Please consult your legal counsel.


If you need ongoing updates related to COVID-19 and our efforts to support you at this time, please contact your account manager.

Additional Resources:

Centers for Disease Control and Prevention (CDC)
World Health Organization (WHO)
New York Times vaccine tracker
Oregon Health Authority
Washington Department of Health
Utah Department of Health
Idaho Department of Health

Testing FAQ
 How will Regence support OTC COVID-19 at-home rapid test claims processing for members?

Claims for members on fully insured plans and self-funded plans with Regence pharmacy benefits will be processed through our PBM, Prime Therapeutics. Prime has set up a “Broad Plus” preferred network of contracted pharmacies, tiered above plans’ other existing networks. With about 65,000 locations nationwide, Prime’s Broad Plus Network is designed to capture the highest volume of tests purchased and ensure pricing does not exceed $12 per test.

 How will Prime manage non-preferred or out-of-network (OON) pharmacies?

To maximize access to members and minimize paper claims being submitted to Prime for reimbursement, Prime will wrap the Broad Plus Network with an adjudication setup for non-contracted pharmacies. Pharmacies with fraud, waste and abuse concerns will be excluded. Members may submit reimbursement requests for any in-network providers that are not set up for electronic submission using existing paper claims processes. Pharmacies not in the Prime Broad Plus Network will be able to submit electronic claims, and reimbursement will be at the lesser of the pharmacy’s usual and customary (U&C) submitted costs, or $12 per test, with no dispensing fee.

Prime will support claims from non-pharmacy retailers, and members purchasing at non-pharmacy retailers can submit claims following the standard paper claims process.

 Which specific COVID-19 OTC test kits are included in Prime’s solution?

Prime’s solution includes test kits that are available without a prescription and do not require a lab to read the results. The following kits are included (this list may expand in the future):

  • ELLUME COVID-19 Home Test (single pack)

  • BIAXNOW COVID-19 AG CARD Home Test (2-pack)

  • INTELISWAB COVID-19 Rapid Test (2-pack)

  • QUICKVUE AT-HOME COVID-19 Test (5-pack and 2-pack)

  • ON/GO COVID-19 ANTIGEN Self-Test (2-pack)

  • FLOWFLEX KIT HOME Test (single pack)

Because molecular products mostly require a prescription and are lab-based tests, Prime considers them to be a medical benefit. Prime’s claim process for electronic or paper claims will deny coverage for tests that are not on Prime's list of covered test kits.

 Will members with a COVID-19 testing requirement for employment be reimbursed when using an OTC test?

No. The OTC tests covered under the reimbursement policy are for diagnosis of COVID-19 when members are experiencing symptoms or have been in close contact with an infected person. For reimbursement, members may be asked to provide an attestation that the test was used to diagnose suspected illness, not for employment, surveillance, attending an event or travel.

 Does this policy cover any at-home test such as a PCR or only rapid tests?

The OTC tests covered under the reimbursement policy are FDA authorized for non-prescription use rapid antigen or rapid PCR diagnostic tests you can perform at and obtain results at home.

 Is testing covered under the medical benefit or pharmacy? For clients with carved-out pharmacy benefits is testing covered by us or the PBM?

Testing will be covered through either members’ medical benefit or pharmacy benefit. It is anticipated that claims will primarily be processed as pharmacy benefits through members’ PBM.

 Is testing coverage the carrier/self-funded groups’ financial responsibility or is there government reimbursement (like with vaccines)?

Insurers and self-funded groups are responsible for paying COVID-19 testing claims.

 Will we allow self-funded groups with PBM carve-out to further carve the OTC tests out of their medical coverage?

We will request attestation from self-funded groups to confirm their plan meets the safe harbor requirements in the guidance. If the plan meets safe harbor requirements, any claims that are received through the medical benefit administration will be paid up to $12 per test. If their plan does not meet safe harbor requirements, any claims that are received through the medical benefit administration will be reimbursed at billed charges and may result in substantially higher charges to the group’s health plan. It’s each group’s responsibility to inform us of their approach in conjunction with their PBM. They will have to cover the costs through pharmacy or medical.

 Will we require PBM safe harbor attestation from self-funded and joint-admin groups, and if so, what form will it take?

Yes. We will request groups with PBM carve-out sign and return an attestation indicating their safe harbor compliance status.

 How are we notifying members about this coverage?

National and local media have extensively covered this policy. We will have information, including an FAQ, for members on our website as well as our Regence news blog and social media. Customer service has also been answering member questions.