COVID-19 Treatment and Cost Share Guidance

Last update: July 20, 2021, 4:00 p.m. CT

UnitedHealthcare has implemented a number of cost-share waivers at different points in the COVID-19 national emergency. Current cost-share waivers are outlined below. For details of past cost share waivers, please review the summary of COVID-19 temporary program provisions.

Treatment coverage may vary by health plan. Please review each section below for details. Some service or facility exclusions may apply. Implementation for self-funded customers may vary. We will adjudicate benefits in accordance with the member’s health plan.

Medicare Advantage

As of April 1, 2021, no cost share waivers are in effect. Coverage and cost share (copay, coinsurance and deductible), including out-of-network costs, are adjudicated in accordance with the member’s health plan. This includes telehealth, inpatient and outpatient COVID-19 treatment for both in-network and out-of-network services.

Individual Exchange, Individual and Group Market fully insured health plans

No cost share waivers are currently in effect. Coverage and cost sharing is adjudicated in accordance with the member’s health plan.

Please see our summary of COVID-19 temporary program provisions for information about the cost share waivers that have previously been in effect.

Medicaid

Waiver of cost share is subject to state requirements. Please refer to your state’s COVID-19-specific website for more information.

Medicare Advantage Plans and Individual and Group Market Fully Insured Health Plans

Beginning Feb. 4, 2020, if a member receives treatment under a confirmed positive diagnosis of COVID-19 or has a COVID-19 admission, providers may bill with codes U07.1 and B97.29. As of Jan. 1, 2021, providers may also bill with code J12.82.

For Medicaid plans, state requirements apply. 

For a full list of associated codes and sequencing codes for COVID-19-related visits, see the ICD-10-CM Official Coding and Reporting Guidelines.

Prior authorization

Prior authorization is not required for administration of these monoclonal antibodies, given the potential benefit of outpatient therapeutic intervention in high-risk patients with early mild to moderate COVID-19. Typical processes and member benefits, including those related to clinical trial participation, if applicable, will apply for outpatient visits.

Billing and reimbursement

For Individual and Group Market, Individual Exchange and Medicaid health plans, providers should only bill for the administration. Health care providers should not include the monoclonal antibody codes on the claim when the product is provided for free. Implementation for self-funded customers may vary.

For Medicare health plans, COVID-19 monoclonal antibody infusion claims should be submitted to the Medicare Administrative Contractor (MAC). Claims will be denied if submitted to UnitedHealthcare. 

Please use the following information when billing for monoclonal antibody treatment:

Drug name

HCPCS code

Administration code

Casirivimab + Imdevimab

Q0243

M0243

Bamlanivimab+Etesvimab

Q0245

M0245


Effective March 24, 2021, the distribution of the solo bamlanivimab prouct was discontinued, and on April 16, 2021, the FDA revoked the EUA based on sustained increase in SARS-CoV-2 viral variants in the U.S. that are resistant to bamlanivimab administered alone. Claims for the solo bamlanivimab product when infused alone, with a date of service of April 16, 2021 or later, will be denied. The two other authorized combination monoclonal antibody therapies – bamlanivimab + etesevimab and casirivimab + imdevimab – remain available and are expected to retain activity to these variants. 

For more information, visit the Center for Medicare & Medicaid Services (CMS) Monoclonal Antibody COVID-19 Infusion page.

Member coverage and cost share

For Individual Exchange, Individual and Group Market health plans, the investigational monoclonal antibody treatment will be considered a covered benefit during the national public health emergency period, currently scheduled to end Oct. 17, 2021. Patients should meet the emergency use authorization (EUA) criteria for FDA-authorized monoclonal antibody treatment in an outpatient setting.

UnitedHealthcare waived cost sharing for the administration (intravenous infusion) of monoclonal antibody treatments for in-network providers in outpatient settings through March 31, 2021.

Out-of-network coverage and cost share is adjudicated according to a member’s health plan.

For Medicare health plans, the CMS Medicare Administrative Contractor will reimburse claims for Medicare beneficiaries with no cost share (copayment, coinsurance or deductible) through 2021.

For Medicaid health plans, Medicaid state-specific requirements may apply. For Medicaid and other state-specific regulations, please refer to your state-specific website or your state’s UnitedHealthcare Community Plan website, if applicable.

Resources

For more information on administration, high-risk patients and treatment availability, please review the following resources:

Medicare Advantage, Individual Exchange, Individual and Group Market fully insured health plans

No cost share waivers are currently in effect. Coverage and cost sharing is adjudicated in accordance with the member’s health plan.

Medicaid

Coverage and waiver of cost share is subject to state requirements. Please refer to your state’s COVID-19-specific website for more information.

Resources

Care providers can connect to the latest Centers for Disease Control and Prevention (CDC) guidance for health professionals, as well as travel advisories from the U.S. State Department.


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Disclaimer:

The benefits and processes described on this website apply pursuant to federal requirements and UnitedHealthcare national policy during the national emergency.  Additional benefits or limitations may apply in some states and under some plans during this time.

We will adjudicate benefits in accordance with the member’s health plan.

Medicaid Providers: UnitedHealthcare will reimburse out-of-network providers for COVID-19 testing-related visits and COVID-19 related treatment or services according to the rates outlined in the Medicaid Fee Schedule.