COVID-19: Coverage for our members
Last updated: Jan. 14, 2022
Member coverage and costs for COVID-19 testing
Tests ordered by a provider
Copays and deductibles are waived for COVID-19 tests deemed medically necessary by a doctor to treat and diagnose a patient’s symptoms. This means there is no member copay, deductible or coinsurance for diagnostic testing of COVID-19. The test must be ordered by a physician or advanced practice provider (APP), a physician assistant or nurse practitioner. We only cover one COVID-19 test per day.
Over-the-counter (OTC) tests
Starting Jan. 15, 2022, we’ll cover FDA-approved OTC diagnostic tests for COVID-19 at $0 cost share and without a prescription for our commercial group and individual members, in most cases. Covered individuals can receive 8 OTC tests within a 30-day period. Tests purchased at the pharmacy counter will be covered with no out-of-pocket expense. If a member gets an OTC test somewhere other than the pharmacy counter (I.e., the regular checkout line), they’ll need to pay for the tests and can then submit a claim for reimbursement at a rate of up to $12 per individual test. If your patients have questions, they can find more information online.
This is in addition to existing coverage for our Medicaid members, who can receive one at-home test per day at $0 cost share when prescribed, and when both the prescriber and dispensing pharmacy are Medicaid enrolled. Get more information from MDHHS.
Member coverage and costs for COVID-19 treatment
COVID-19 treatment is available to our members with no out-of-pocket health plan costs when received from an in-network provider between the dates of Mar. 11– Sept. 30, 2021.*
- Covered treatment may be inpatient or outpatient from an in-network provider. Patients must have a confirmed primary COVID-19 diagnosis and be receiving evidence-based care for treatment to be fully covered.
- If a member visits an out-of-network doctor, their treatment will be covered as outlined by their health plan and cost sharing will apply, if applicable. Note that some plans do not have out-of-network benefits. We encourage members to receive care from providers in our network.
- Monoclonal antibody treatments must have Emergency Use Authorization (EUA) from the FDA for their administration to be covered. Learn more about the FDA's monoclonal antibody limitations.
Learn more or share information with your patients using our COVID-19 FAQ page for members.
*Employer plans that are self-insured determine benefit coverage for their employees and dependents at their discretion.
Member coverage and costs for virtual visits
Member costs for virtual services vary by plan. Many plans that had $0 cost share have returned to the member’s standard benefit offering. Some plans will continue to have $0 cost share through Dec. 31, 2021**.
For more information about billing for virtual visits, HIPAA requirements, virtual care policies and more, visit our COVID-19 virtual visits information page for providers.
**Beginning Jan. 1, 2021, our standard benefit offering continues to include $0 virtual care services for fully funded plans. Among large and small groups, there are variations of benefit coverage and members may have costs, for example, grandfathered plans, union negotiations, non-standard plans, etc. Employer plans that are self-funded determine benefit coverage for their employees and dependents at their discretion. Excludes virtual visits as part of virtual-first PCP plans. Our Vital Medicare plan has a 20% coinsurance for virtual visits.
Free access to COVID-19 mental wellness tools
To empower our members we've partnered with a digital health specialist to offer free access to MyStrength, a mental wellness resource specifically focused on the COVID-19 pandemic.
For immediate behavioral health support
Our on-staff behavioral health team is available 24 hours a day, seven days a week. Members should call the number on the back of their member ID card or log in to their member center.
Frequently asked questions: member coverage
What options do my patients have for getting prescriptions?
Priority Health members can get free at-home delivery for a limited time through a few retail/local pharmacy vendors. Learn more on our COVID-19 member page in the FAQs.