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To: Medicare contacts and pharmacy directors
Impacted: This topic impacts Medicare
Medicare COVID-19 coverage changes post-PHE
Prime is taking action to update Medicare coverage flexibilities implemented by the Centers for Medicare & Medicaid Services (CMS) during the COVID-19 pandemic.
For details from CMS, see the March 24, 2023 memo titled Coronavirus Disease 2019 Related Exercise of Enforcement Discretion Ending May, 11, 2023.
NOTE: in this memo, CMS indicates that members should be notified of changes to benefits. Since Prime is unaware of any changes clients may have made to medical benefits during the COVID-19 Public Health Emergency (PHE), Prime advises clients to notify members of these changes. See final paragraph of the March 24 CMS memo.
Post-PHE coverage changes
The COVID-19 PHE expires May 11. Prime is deactivating all COVID-related Medicare coverage flexibilities effective May 11. Clients have two options in response:
- Clients can choose to adhere to deactivation of all coverage flexibilities. Your members’ Medicare coverage will reflect these coverage changes starting May 11. No action is needed.
- Clients who have special coverage requests should contact their client engagement representative.
Coverage flexibilities to be deactivated
Here are the coverage flexibilities that Prime will deactivate May 11 in keeping with CMS guidance due to the end of the COVID-19 PHE:
- Retail – 90 Day Supply (DS) (If applicable)
- Transition – 90 DS including emergency fills
- Out of Network – 90 DS (if applicable)
- Home Infusion – 90 DS (if applicable)
- Long-term care – 90 DS
- Specialty Tier – 90 DS (if applicable)
- Supplemental coverage – 90 DS (if applicable)
Please note, if your plan opted to make any flexibilities permanent benefits by updating your bids and the Benefit Edit Tool, these will remain in place.
Client considerations
- Coverage for at-home COVID test kits has reverted to being a client-managed benefit. As of May 11, Prime’s point-of-sale messaging directing pharmacies to submit claims via Original Medicare will be turned off.
- Concurrent drug utilization review (cDUR) assessing drug-disease interaction for Hydroxychloroquine/Chloroquine will be deactivated May 11.
- For prescription drug delivery signature flexibilities, Prime will no longer allow "Covid" in lieu of signature after May 11.
Other updates
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If you still have a Dynamic Prior Authorization (DPA) in place to override the refill-to-soon edit, the DPA put in place during the pandemic will end on May 11, 2023. No action is needed from clients who have already turned off the DPA. Prime will continue to follow our standard procedure of activating DPAs during declared natural disasters.
If you have questions, please contact your Prime Client Engagement representative.
To access additional Prime client communications and resources, check out the Prime Client Portal. If you don't have access to the portal, contact your IT administrator to request access, just as you would to access any Prime application.
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