Article
Published Feb 11, 2022 • by AHIP
Following recent guidance from the Biden Administration, health insurance providers are covering the costs of over-the-counter tests for COVID-19. Below are recent announcements from health insurance providers, guiding their members on how to access these covered tests.
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Fully insured members may select up to 8 at-home rapid OTC COVID-19 antigen tests at local or online in-network pharmacies for each covered member of their family each month. The members plan should cover the cost of eligible tests with no out-of-pocket expense. Please be aware that most tests are packaged in sets of 2. If members purchase boxes containing 2 tests each, they should be covered for 4 boxes.
Avera Health Plans is partnering with CVS Caremark to provide members with a preferred network of OTC retailers to obtain approved at-home COVID-19 tests. Members may visit any in-network pharmacy and receive approved at-home COVID-19 tests without paying any upfront costs.
AvMed employer-sponsored and Individual & family plan members can obtain up to 8 free OTC COVID-19 at-home tests per member per month by presenting their AvMed ID card to any AvMed in-network pharmacy. In-network pharmacies include but are not limited to CVS, Sam’s Club, Walmart, and Publix. Eligible AvMed Members may purchase at-home tests at retail locations outside AvMed’s preferred pharmacy network and submit receipt(s) for the reimbursement of the paid retail price (up to $12 per test).
Capital District Physicians’ Health Plan
Capital District Physicians’ Health Plan (CDPHP) is covering at-home COVID-19 test kits that are FDA approved or have been issued an EUA by the FDA. At this time, for all commercial members (including self-funded), CDPHP is reimbursing for kits purchased out of pocket (up to $12 per test or $24 for a kit containing two tests). Members may obtain up to 8 tests (or 4 kits containing 2 tests) per covered family member, per month. To avoid an upfront cost, members will need to purchase the test kit at a pharmacy window or pharmacy counter of a pharmacy in the CDPHP network. If members choose to purchase a test kit at a non-participating pharmacy or other retailer, there will be an upfront cost with reimbursement.
Effective January 15, 2022 and through the end of the Public Health Emergency period, OTC tests that are approved under the FDA emergency use authorization (EUA) in vitro diagnostics will be covered at $0 cost to the customer, without a health care provider order or individualized clinical assessment. If a member purchases an over-the-counter COVID-19 test from a pharmacy, store, or online retailer and is charged, they can keep their receipt and submit a claim to Cigna for reimbursement. Members will be reimbursed the costs of diagnostic OTC testing, regardless of where the tests are obtained (in- or out-of-network).
Harvard Pilgrim Health Care is covering the cost of up to 8 OTC, at-home COVID-19 tests per member, per month for commercial members. Harvard Pilgrim will pay only for tests that are approved by, or granted emergency use authorization by, the FDA, are intended for individualized diagnosis or treatment of COVID-19 (not for resale), and are not for employment purposes. 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 with copies of receipts. The form includes instructions on how to submit for reimbursement.
Per federal guidelines, Highmark’s commercial members can seek reimbursement for up to 8 qualifying over-the-counter COVID-19 tests per month. To get reimbursed, members should submit a manual claim form through the member portal, located at highmarkbcbs.com, and upload a copy of their receipt and UPC label from the test. Highmark is also working to have additional options for members to get reimbursed, or to purchase a test from a participating pharmacy or retailer without any up-front costs.
Coverage includes at-home COVID-19 test kits authorized by the Food and Drug Administration (FDA). Covered members can get up to 8 individual tests per month at Walmart, Sam’s Club, Rite Aid, and Walgreens for no out-of-pocket cost. Members can also purchase an FDA-authorized OTC COVID-19 test kit at other stores or online retailers. In that case, they need to keep their purchase receipt(s) to submit for reimbursement.
Independent Health commercial and self-funded plan members can go to their pharmacy, a store, or online to obtain a OTC COVID-19 diagnostic test authorized by the U.S. Food and Drug Administration (FDA). Members who have purchased a test on or after January 15, 2022, can log in to their secure MyIH account and submit a claim.
Starting January 15, 2022, L.A. Care members in commercial L.A. Care Covered Plans and PASC-SEIU Homecare Workers Health Care Plan may obtain up to 8 OTC COVID-19 rapid antigen tests per month at no cost, either through an L.A. Care network pharmacy or L.A. Care’s mail order pharmacy. At retail locations such as CVS, members must pick up the test through the pharmacy and show their L.A. Care member ID card to verify eligibility. L.A. Care will reimburse members up to $12 for tests purchased outside of an L.A. Care network pharmacy.
For the duration of the national public health emergency, Medica members enrolled in individual plans and commercial fully funded and self-funded plans are covered for OTC FDA-authorized COVID-19 antigen tests without a prescription from a qualified health professional. Coverage includes up to 8 FDA-approved OTC COVID-19 antigen home tests for each member per month covered under a subscriber's plan. Tests can be obtained through a network pharmacy at no cost using a Medica ID card. Tests obtained at an out-of-network pharmacy or retailer are eligible for reimbursement at $12 per OTC test.
Moda Health members can now get free OTC COVID-19 tests. Members with individual and family or employer group coverage can obtain a free test at their in-network pharmacy by showing their Moda member ID card. If a pharmacy can’t process the order, members can buy the test at the pharmacy or at another in-person or online retailer, then use a claim form to get reimbursed.
Neighborhood Health Plan of Rhode Island
Throughout the public health emergency, Neighborhood will cover the cost of up to 8 FDA-approved, at-home COVID-19 rapid antigen tests, without a prescription for Neighborhood Commercial members. Each member on the Neighborhood Commercial plan is covered for up to 8 home self-test kits every 30 days. Members can obtain an OTC rapid antigen test in-store at a Neighborhood preferred network pharmacy by presenting their member ID card, or they can purchase a test from any pharmacy or online retailer and request reimbursement.
Effective January 15, 2022, Optima Health will provide coverage of certain over-the-counter, COVID-19 diagnostic tests (OTC COVID-19 tests) for commercial members covered under its individual or employer group health plans. The easiest way for a member to get a COVID-19 test kit, with no out-of-pocket costs, is to order online through Optima Health’s partner. OTC COVID-19 test kits will be available for ordering online this week and kits will be delivered within 48 hours. Any commercial member that chooses not to use online ordering through their partner, and therefore pays out-of-pocket for covered OTC COVID-19 tests on or after January 15, 2022, can submit a claim to Optima Health for reimbursement.
PacificSource Health Plans commercial members can now obtain at-home COVID-19 tests, through CVS Caremark, at $0 member cost share at participating pharmacies, subject to available supplies. Eligible members may receive up to 8 at-home COVID-19 tests every 30 days without a prescription. Please note that some at-home COVID-19 test kits include multiple tests; the number of individual tests in the box will be counted toward the 8 test maximums. To be covered in full, with no member cost share, members must use an in-network pharmacy and go to the pharmacy window to request the tests. They need to present their member ID card, and the pharmacist will process the transaction.
Physicians Health Plan of Northern Indiana
Physicians Health Plan of Northern Indiana covered members may receive free FDA-Approved OTC tests through PHP’s preferred pharmacy network. Members must obtain a test directly from the pharmacist at a PHP participating pharmacy location to avoid any up-front costs. Because of the short implementation window for this mandate, members also have the option of purchasing FDA-Approved OTC tests and then submitting documentation to PHP for reimbursement.
Members who have plans that cover the costs of OTC COVID-19 antigen rapid at-home tests can get tests through an in-network pharmacy at no cost. Members must select tests that are authorized by the FDA. Tests must be purchased at the pharmacy's check-out counter and members must show their Security Health Plan ID card.
Sutter Health Plus covers COVID-19 screening for members in accordance with state and federal guidelines during this public health emergency. This includes FDA-authorized OTC COVID-19 tests available for purchase directly through pharmacies, retailers, or online. Sutter Health Plus limits coverage of OTC COVID-19 tests bought without a prescription or clinical assessment by a provider to 8 tests per member, per 1-month period. While members can purchase the tests without a prescription or other clinical assessment by a provider, Sutter Health Plus encourages members to contact their primary care physician to see if testing is recommended for their particular situation. There are no quantity limits when a treating physician orders a test as part of an individual clinical assessment.
Tufts Health Plan is covering the cost of up to 8 OTC 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. 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 with copies of receipts. Medicaid members can obtain coverage for 5 branded OTC tests through their pharmacy benefits. Guidance on coverage for our MassHealth, Senior Care Options and Unify members will be available in the coming days.
Individual & Family Plan members can get up to 8 FDA-approved OTC tests every month at no cost. Members have 2 options to get their at-home COVID-19 tests. By showing their UCare ID card at the pharmacy counter, members won’t have to pay anything. If a pharmacy can’t process this request or a member has to pay for the tests themselves, they can ask UCare to reimburse them. Members can also pay the full cost of the tests when they check out, then download, fill out and send in a Claim Reimbursement Form. UCare limits reimbursement to the lesser of actual cost or $12 for each test.
University Health Alliance (UHA)
UHA is covering the costs of FDA-authorized OTC COVID-19 diagnostic test kits. These tests are covered without the need for a provider’s order, clinical assessment, or other medical management requirements, and at no out-of-pocket cost to members. Eligible tests will be at no cost to a member when purchased through a preferred participating pharmacy in UHA’s network. A portion is reimbursable if purchased through an online retailer or at a retail store.
UPMC Health Plan has announced immediate and developing processes to enable members covered by employer or individual plans to seek reimbursement for COVID-19 tests in accordance with recent federal requirements. Forms and details on the current manual submission process are available at upmchealthplan.com/covid-19/, where up-to-date information regarding vaccines, testing and COVID news are also posted.
Members with prescription drug coverage through VIVA Health may now purchase eligible at-home COVID-19 diagnostic tests from the pharmacy counter at a participating pharmacy and receive the tests at no charge if they haven’t reached their 30-day limit and they present their member ID. Members should ask the pharmacy if its system is set up to allow the purchase through their pharmacy benefit. Members who buy tests at a participating pharmacy but do not buy them at the pharmacy counter using their VIVA Health member ID card or who buy tests outside the participating pharmacy network will have to pay out of pocket, and reimbursement will be limited to $12 per test.
OTC COVID-19 diagnostic tests authorized by the FDA will be covered at no cost for Western Health Advantage (WHA) members. WHA members who purchase an FDA-approved COVID-19 diagnostic test on or after January 15, 2022, will be able to submit a reimbursement request form, with a scanned receipt, for the cost paid - up to $12 per diagnostic test. Members can also visit a preferred test pickup pharmacy and simply show their WHA ID Card, and the pharmacist will dispense the OTC tests at no charge at time of pickup.
WPS Health Insurance and WPS Health Plan will cover the costs of home testing kits in accordance with new federal requirements. Individuals with private health insurance coverage or covered by a group health plan who purchase an over-the-counter COVID-19 diagnostic test authorized, cleared, or approved by the U.S. Food and Drug Administration—online or at a store—can be reimbursed for the full cost beginning Jan. 15, 2022. This coverage will apply until the end of the public health emergency.