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  • RxSense

Five Days to Comply with Government Mandate

Updated: Jun 13



The continuing Public Health Emergency (PHE) initiated in response to the COVID-19 pandemic has presented a myriad of challenges, the latest of which was the government mandate on Jan. 10, 2022, for insurers to cover the cost of at-home rapid result COVID test kits by Jan. 15, 2022. According to a Kaiser Family Foundation news release on Jan. 20, 2022, just seven of some of the largest insurers who responded were able to roll out that coverage, and only by Direct Member Reimbursement (DMR)1.


All of our clients, however, had a short-term solution in place by Jan. 15, 2022 (just 5 days after the mandate) – and it did not require members to pay anything out of pocket, complete and submit any forms, and wait for reimbursement. Clients had the option to opt out of this solution as well. We quickly followed with fully customizable enhancements from quantity limits to pricing to benefits throughout the hierarchy by client and pricing.


The Complexity of the Challenge

The challenge of this mandate for RxAgile was not the five-day timeline, though that certainly added to the urgency. The real challenge was in the complexity of each of the components affected by this mandate:

  • This was an entirely new type of benefit to configure.

  • Medi-Span National Drug Codes (NDCs) needed to be combed through for “reasonably” priced test kits to be covered.

  • Clinical rules and quantity limits needed to be updated to override every other rule against those NDCs.

  • Client, engineering, data, clinical, network, benefits administration, QA, service delivery, and account management teams needed to be in sync, review, and agree upon short and mid-term goals and parameters.

How We Did It

To ensure that members could walk into a pharmacy, pick up a test kit, and not have to pay anything at point of sale (POS), our Industry Standards and Innovations team quickly aligned resources for a swift response. The first step was to manually identify all the COVID test kit NDCs in Medi-Span. We checked Medi-Span daily for any new NDCs that were both reasonably priced and packaged. Our formulary operations team learned that, while some kits were priced ($10-$15), there were far more that were over $100. To meet both the deadline and our fiscal responsibility to our clients and their members, we narrowed the list to a limited number of NDCs that could be configured for coverage that met our criteria.


While the formulary team worked the clinical side, the engineering team investigated the most effective way to implement this new type of benefit. They determined that using RxAgile’s set of rules and lists functionality, we could use the list of NDCs from the formulary team and apply a rule that would be applied to all levels below and override all other rules for those NDCs in any benefit plan across a client’s entire book of business. Not all clients would want such a global rule, so we let them decide, during this first phase, whether to opt out.


To test how well this solution would work, all teams worked in concert to test the solution from claims adjudication all the way through to reimbursements, verifying results in RxIQ®.


After client acceptance, the solution was rolled out globally to all clients (who hadn’t opted out). During this process, we identified a number of other enhancements that would make this solution even more robust. We quickly followed the initial roll-out with refinements of:

  • Age, quantity, and pricing limits.

  • Rules in identifying more, qualified NDCs.

  • Where the lists should be attached in the client’s hierarchy structure.

  • Reimbursement rate flexibility.

Any client, including those who initially opted out, can now apply these to their own plans.


The Solution

This solution, delivered in just five days, highlights the incredible flexibility built into our adjudication platform, RxAgile. Because of how sets of rules and lists can be inherited throughout every or any level of a hierarchy, new benefit configurations are a snap. This also draws attention to the flexibility and agility of our cross-functional teams to quickly assess, distill, and solve problems in ways that benefit both our clients and their members. Further, this kind of solution ensures the pharmacies we work with also have a positive experience with members at the POS. This is a perfect example of how our truly transformative technology enables our clients to be successful.


1 Submission of a claims form and receipts for later reimbursement by the plan.

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