COVID-19 OTC Diagnostic Testing Resources from Carriers
On Jan. 10, 2022, the Depts. of Labor, Health and Human Services (HHS), and the Treasury issued FAQ guidance regarding the requirements for group health plans and health insurance issuers to cover over-the-counter (OTC) COVID-19 diagnostic tests.
Plans and issuers must cover the costs of COVID-19 tests during the COVID-19 public health emergency without imposing any cost-sharing requirements, prior authorization, or other medical management requirements.
Under guidance issued in June 2020, at-home COVID-19 tests had to be covered only if they were ordered by a health care provider who determined that the test was medically appropriate for the individual. At that time, the FDA had not yet authorized any at-home COVID-19 diagnostic tests. Since then, several types of OTC at-home tests have been approved.
As of Jan. 15, 2022, the cost of these tests must be covered, even if they are obtained without the involvement of a health care provider. However, the FAQs do not require tests to be covered if they are not for individualized diagnosis (such as tests for employment purposes).
Plans and insurance issuers may place some limits on coverage, such as:
- Requiring individuals to purchase a test and submit a claim for reimbursement, rather than providing direct coverage to sellers.
- Providing direct coverage though pharmacy networks or direct-to-consumer shipping programs and limiting reimbursements to other sources (the actual cost of the test, or $12, whichever is lower).
- Setting limits on the number or frequency of OTC COVID-19 tests that are covered (no less than 8 tests per month or 30-day period).
- Taking steps to prevent, detect and address fraud and abuse.
Allstate (National General)
Allstate Benefits is working hand in hand with third party administrators (TPA) to outline a process for members to receive reimbursement for these tests from their group health plan. A full process for member reimbursement under group health plans will be announced and communicated as developed.
In the interim, here is some helpful information regarding the new COVID-19 home test coverage:
- With a shortage in available home tests at local pharmacies, stores, and online retailers, members may want to first try obtaining their home tests directly from the government website, where ordering is to be available as of January 19, 2022. The website to obtain tests is here: covidtests.gov
- If members choose to purchase their tests via pharmacies, local stores or online retailers they will be able to submit a COVID Home Test Claim form for reimbursement under their group health plan.
While the process is being finalized, members should keep this information in mind:
- First dollar coverage for FDA approved COVID-19 home tests without an ordering physician is only available for tests purchased on or after January 15, 2022.
- If a member purchases a home test for themselves or another covered individual on their plan they should be sure to save a hard copy of the receipt of purchase and cut out the UPC code on the test box for reimbursement purposes.
- Coverage for home tests is limited to 8 tests per month, per covered individual on the plan.
If you have any questions in the meantime please contact your Allstate Benefits Account Manager at 888-659-1859.
AllWays Health Partners
AllWays Health Partners has ensured timely access to critical health care services for our members throughout the pandemic and continues to do so by making FDA approved, at-home COVID-19 tests available at no cost in accordance with new federal guidance.
Beginning January 15, 2022, members of AllWays Health Partners will have up to 8 FDA approved at-home COVID-19 tests covered per member per month. Please note member reimbursement is limited to up to $12 per test. This policy will remain in effect for the duration of the federal public health emergency.
As of January 15, fully commercial members* can obtain these tests through a pharmacy and submit for reimbursement through www.Caremark.com. Remember to save a copy of your receipt.
AllWays is also working with our partners to establish a process to obtain these tests at no cost at the time of your purchase. More information will be shared on our COVID-19 Resource Center when this process is finalized.
My Care Family members can receive up to 8 FDA approved at-home COVID-19 tests through network retail pharmacies. My Care Family members should visit the pharmacy counter for more information on obtaining a MassHealth covered test at no cost.
*Employers whose pharmacy benefit is not covered through AllWays Health Partners may have different processes in place for their members. Please consult with your pharmacy benefits manager.
Blue Cross Blue Shield of MA
As of January 15, 2022, Blue Cross Blue Shield of MA will cover up to eight self-administered at-home tests per commercial member per month for personal, diagnostic use, without cost-share and without any need for prior clinical assessment.
The coverage is not retroactive and will not apply to any test kit purchases made prior to January 15, 2022.
Eligible members can complete the COVID-19 At-Home Test Reimbursement form (PDF)
For more complete information on the new policy, visit here for details.
Additionally, Blue Cross Blue Shield of MA will continue to cover FDA-authorized COVID diagnostic tests, such as PCR tests, with no cost share to members when ordered or administered by a health care provider following an individualized clinical assessment. This applies to our commercial and Medicare members.
Blue Cross Blue Shield of RI
3 things to know about $0 home test kit coverage
- Each person on a BCBSRI non-Medicare plan is covered for up to 8 home test kits every 30 days.
You don’t need a prescription or order from a healthcare provider. For a list of covered home test kits, please see the FAQs here.
- If you buy the tests at a participating pharmacy (at the pharmacy counter), you will pay $0 when using your BCBSRI member ID card.
Even if a pharmacy is not participating in the BCBSRI network, you may be able to buy the test for $0, so please ask at the pharmacy counter. If you buy the tests at a retail store or online, you’ll need to submit a form, along with your receipt, and will be reimbursed up to $12 per individual test. If a test is sold in a package of two, that is considered two tests, and you will be reimbursed $24.
- The BCBSRI participating pharmacy network for COVID-19 home test kits includes approximately 65,000 pharmacies nationwide, including CVS and Walgreens.
Please note that this network may be different than your plan’s standard pharmacy network. A directory of the participating pharmacies nationwide will be available soon. Find participating pharmacies in Rhode Island.
Effective January 15, 2022 and through the end of the Public Health Emergency (PHE) period, Cigna will cover OTC tests that are approved under the FDA emergency use authorization (EUA) in vitro diagnostics at $0 cost to the customer, without a health care provider order or individualized clinical assessment. If you purchase an over-the-counter COVID-19 test from a pharmacy, store, or online retailer and are charged for your test, keep your receipt and submit a claim to Cigna for reimbursement. You will be reimbursed the costs of diagnostic OTC testing, regardless of where the tests are obtained (in- or out-of-network). Your plan can provide this coverage through reimbursement to you. Your plan can require you to sign an attestation that the test:
- Was purchased for the covered individual;
- Is not for employment purposes;
- Has not and will not be reimbursed by another source, and
- Is not for resale.
Your plan may require reasonable documentation of proof of purchase with a claim for reimbursement for the cost of an OTC COVID-19 test. Examples of such documentation could include the UPC code for the OTC COVID-19 test and/or a receipt from the seller of the test, documenting the date of purchase and the price of the OTC COVID-19 test.
To get reimbursed for tests purchased after January 15, download and print a COVID-19 Over-the-Counter (OTC) Test Kit Claim Form [PDF]
Harvard Pilgrim Health Care
Harvard Pilgrim Health Care is covering the cost of up to eight over-the-counter, at-home COVID-19 tests per member, per month for commercial members. Tests must be approved or granted emergency use authorization by the FDA. View list.
- Harvard Pilgrim Health Care Commercial members can visit a Walmart or Rite Aid pharmacy and purchase the tests with no upfront cost.
- Commercial members paying for at-home tests out-of-pocket can also print a form and mail it to us with copies of receipts. The form includes instructions on how to submit for reimbursement.
Although not mandated by the federal requirements, HPHC is working with CMS to determine if they can provide coverage for at-home COVID-19 tests for their Medicare members. HPHC is also working with state officials in Rhode Island to determine if they can cover the tests for those enrolled in their Medicaid plans.
Updates to their current COVID-19 policies will be published to the COVID-19 resource centers on their websites when available.
Health Plans, Inc. and Southern Scripts
Starting January 15th, health benefit plans must cover FDA approved at-home over-the-counter COVID-19 diagnostic tests (tests) without the involvement of a health care provider, and without imposing cost sharing or prior-authorization requirements. If the Plan’s pharmacy benefit manager (PBM) will provide direct coverage of the tests, members can obtain the tests free of charge at point of sale. Any tests that members purchase outside the PBM’s network offering will be reimbursed up to $12 per test. If the Plan’s PBM will not provide direct coverage, members can submit a claim to the Plan for full reimbursement of the cost of the test. Coverage is limited to no more than eight (8) tests per member per 30-day period. Please note that Plans are not required to provide coverage of testing (including an at-home over-the-counter COVID-19 test) that is for employment purposes.
Health Plans, Inc. has reached out to their PBM partners, as well as clients’ direct PBM partners, to inquire whether the PBMs would provide for direct coverage of the at-home tests and, if so, whether they would also process member reimbursements for tests purchased outside of the network benefit. To date, all PBMs that have responded have indicated they will provide direct coverage through the pharmacy benefit and process member reimbursements. As such, HPI is taking the following actions:
SMMs: HPI will draft a Summary of Material Modification (SMM) for clients’ medical benefit plans to amend the plans effective January 15, 2022 to provide coverage for the at-home tests.
The SMM will indicate coverage is provided as follows:
- Coverage of FDA approved over-the-counter COVID-19 at-home tests without any cost sharing (e.g. deductibles, copayments or coinsurance), prior authorization or other medical management requirements.
- Coverage for the at-home tests is provided directly through the Plan’s Prescription Benefits Administrator’s (PBM) pharmacy network or preferred retailers with no upfront out of pocket costs.
- If the network pharmacy does not have any at-home tests available or the pharmacy has not implemented operations to support direct coverage, Covered Persons can purchase the tests at an out of network pharmacy or on-line and submit to the PBM for reimbursement which will be limited to the lesser of the cost of the test or $12.
- Coverage for over-the-counter COVID-19 at-home tests is provided exclusively through the PBM benefit. The tests are not otherwise covered or reimbursable under the Plan.
- The Plan will cover up to 8 tests per Covered Person, per 30-day period.
A section has been added to the HPI Website COVID-19 Information Page to provide members with benefit coverage information about the at-home tests which can be found here.
For RogersGray Health Plans Inc. members using Southern Scripts, you will have the ability to present your pharmacy identification card to a contracted network pharmacy. Network pharmacies may then submit a claim for OTC COVID-19 tests through their point-of-sale system, which will result in a paid claim at no cost to you.
Please note that this does not a) ensure a network pharmacy has tests available; and/or b) ensure the pharmacy has implemented operations to support claims submission; therefore, Southern Scripts will also support reimbursement of OTC COVID-19 Tests purchased outside of the Direct Coverage Program through our standard manual claims process:
To complete the online form:
1. Visit https://portal.southernscripts.net/member/claim?direct=true
2. Complete the form
3. Upload the receipt for the OTC COVID-19 Test
Manual claims reimbursement may be capped at $12 per test and a max of 8 tests per 30 days.
More information will be forthcoming. For detailed information about OTC COVID-19 Test coverage, we suggest reviewing the FAQs.
Please note that processing through your prescription benefit will be dependent on the filling pharmacy as their operations and policy may or may not allow.
Below is a list of some other common PBMs and how to obtain more information for at-home test kit coverage.
Tufts Health Plan
Tufts Health plan is covering the cost of up to eight over-the-counter, at-home COVID-19 tests per member, per month for commercial, Tufts Health Direct, MassHealth, Senior Care Options and Unify members. Tests must be approved or granted emergency use authorization by the FDA.
Tufts Health Plan Commercial and Tufts Health Direct members
- Commercial and Direct Members should visit the Caremark website for the most up to date information on participating pharmacies to purchase the tests with no upfront cost.
- Commercial and Direct Members paying for at-home tests out-of-pocket can also print a form and mail it to us with copies of receipts. The form includes instructions on how to submit for reimbursement.
- Medicaid members can obtain coverage for five branded, over-the-counter tests through their pharmacy benefits. Guidance on coverage for our MassHealth, Senior Care Options and Unify members will be available in the coming days.
Although not mandated by the federal requirements, Tufts Health Plan is working with CMS to determine if they can provide coverage for at-home COVID-19 tests for their Medicare members. They are also working with state officials in Rhode Island to determine if they can cover the tests for those enrolled in their Medicaid plans.
Updates to current COVID-19 policies will be published to COVID-19 resource centers on Tufts Health Plan websites when available.
On Jan. 15, 2022, UnitedHealthcare began covering most commercial individual and group health plan members’ FDA-authorized or approved OTC COVID-19 at home tests without a doctor’s prescription or clinical assessment. This COVID-19 at home test benefit includes up to 8 tests per member per 30 days.
UnitedHealthcare fully insured and Level Funded individual and group health plan members will have two ways that they can receive reimbursement for these COVID-19 at home test kits.
- Preferred Retailers — UnitedHealthcare has developed and deployed a solution of Preferred Retailers for coverage of OTC COVID-19 at home test kits. A Preferred Retailer is a pharmacy that UnitedHealthcare has made arrangement with to provide an OTC COVID-19 at home tests at no cost to the member at time of purchase or later. The list of Preferred Retailers and their websites may be found in the Preferred Retailer list on uhc.com. UnitedHealthcare is working to add additional Preferred Retailers.
- Other retailers or online — If the member purchases a COVID-19 at home test at any in-store or online retailer other than at the in-store pharmacy counter, they may submit purchase receipt(s) for reimbursement at the UnitedHealthcare member portal for a maximum reimbursement of $12 per test. Many COVID-19 tests are sold as a two-pack so that means the test pack would be reimbursed at $24 ($12 for each test).
A member must be a UnitedHealthcare commercial individual or group health plan member and have UnitedHealthcare’s Pharmacy benefit to purchase OTC COVID-19 at home tests at the Preferred Retailer at no cost using their UnitedHealthcare member ID card. As mentioned earlier, the member may also purchase and then submit a receipt for reimbursement at the retail location of their choice.
Where to get information
Please note the information provided above has been provided by carriers and is not exhaustive. Visit your specific carrier’s COVID-19 Resource Center on their website for more up to date information.