COVID-19 Treatment and Cost Share Guidance

Last update: January 28, 2022,  4:30 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.

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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.

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 April 15, 2022. 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 Advantage health plans, the CMS Medicare Administrative Contractor will reimburse claims for Medicare beneficiaries with no cost share (copayment, coinsurance or deductible) through 2021. Effective Jan. 1, 2022, UnitedHealthcare will reimburse claims for Medicare beneficiaries with no cost share (copayment, coinsurance or deductible). 

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:

Oral therapies

In late December 2021, two new oral therapies (Paxlovid and Molnupiravir) received an emergency use authorization (EUA) to treat mild-moderate COVID-19. Individuals appropriate for treatment are those with a positive COVID-19 viral test result and who are at high risk for progression to severe COVID-19, including hospitalization or death.

Paxlovid is authorized for adults and children 12 years of age and older weighing at least 40kg. Molnupiravir is only authorized for adults for whom alternative COVID-19 treatment options authorized by FDA are not accessible or clinically appropriate. Both therapies should only be prescribed by physicians, advanced practice registered nurses and physician assistants that are licensed or authorized under state law to prescribe drugs in the anti-infective class.

The federal government has purchased initial supplies of these oral therapies and there will not be a cost for the drug treatment. We will pay a professional fee to dispensing pharmacies. 

Infusion therapy

On Jan. 21, 2022, the Food and Drug Administration (FDA) expanded the approved and authorized indications for Veklury (remdesivir) to be used in non-hospitalized adults and pediatric patients with a positive COVID-19 viral test. Coverage for outpatient administration of Veklury is effective as of Dec. 23, 2021.

Since remdesivir can only be administered by an authorized healthcare professional, either in a hospitalized or outpatient setting, it’s not part of the PDL or formulary. Coverage via pharmacy benefits may be permitted by exception where required by state and/or federal regulations (e.g., Part D may cover if a caregiver is unable to procure the medication and instead secures the medication subsequent to the issuance of a prescription).

Individual and Group Market, Individual and Family Plans and Medicaid

Monoclonal antibody treatment: Health care professionals should only bill for the administration. Do not include the monoclonal antibody product codes on the claim when the product is provided for free. Implementation for self-funded customers may vary.

Medicare

Effective Jan. 1, 2022, charges for monoclonal antibody infusion and antiviral treatments, including administration charges, should be submitted to UnitedHealthcare following the standard claims process. Any claims for Medicare beneficiaries that are submitted to the MAC during this timeframe will be denied, and health care professionals will be directed to submit the claims to UnitedHealthcare.

For monoclonal antibody and antiviral services rendered through Dec. 31, 2021, bill claims to the applicable Centers for Medicare & Medicaid Services (CMS) Medicare Administrative Contractor (MAC).*  Any COVID-19 monoclonal antibody infusion claims for Medicare beneficiaries that are submitted to UnitedHealthcare will be denied, and health care professionals will be directed to submit the claims to the MAC.

Please use our COVID-19 Billing Guide when billing for COVID-19 treatment.

Effective March 24, 2021, the distribution of the solo bamlanivimab product 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.

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

For Medicare health plans, administration claims for FDA-authorized or approved COVID-19 monoclonal antibody or antiviral treatments for Medicare beneficiaries will be reimbursed with no cost share (copayment, coinsurance or deductible) through the national public health emergency.

Reimbursement and cost share waivers are limited to monoclonal antibody and antiviral treatments that are FDA-authorized or approved at the time of treatment.

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.

Please review the COVID-19 Billing Guide for details on billing codes.

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.