Over-the-counter COVID-19 tests FAQ

For employer groups

The Biden Administration announced that it is offering at-home tests for free through a federal website. How can a person order COVID-19 tests for their household?­

Every U.S. household can order up to four free at-home COVID-19 tests.

Where can members get tests?

We are working with our pharmacy benefit manager to provide a preferred network of providers and direct-to-consumer shipment program. Employer groups that offer employees prescription drug benefits through Capital Blue Cross will get this solution effective January 15, 2022. The network includes nearly 65,000 pharmacies nationwide, including many national chains, such as CVS, Rite Aid, Walmart, Target, and several grocery stores. The network will be augmented by additional non-contracted pharmacies that have agreed to accept the administration’s recommended $12 cost for each test. The network excludes any pharmacies for which our pharmacy benefit manager has fraud, waste, and abuse concerns.

My group does not have prescription drug coverage through Capital Blue Cross? Will you still be able to cover the cost of OTC COVID-19 tests for our employees?

Members can enjoy a better consumer experience when getting their tests from a pharmacy using their plan’s prescription drug benefits. When they do, they will not have to save receipts, submit claims, or pay anything at the pharmacy counter.

However, we can also cover the OTC COVID-19 tests through the member’s medical benefits; however, it will require several steps and much more time to process reimbursement. Your covered members will be required to submit a claim form and receipt(s) verifying the purchase. Members must submit a receipt with the date of purchase, test name and dollar amount, and retailer name. Additionally, members should complete sections 1, 2, and 7 of the medical expense claim form so that we can correctly process the claim.

Members should ensure that the receipt includes the following information:
  • Retailer name.
  • Date.
  • Dollar amount of test(s).
  • Quantity of test(s).
  • Name of test.

Some pharmacies have asked our employees to pay for the OTC COVID-19 tests and submit a claim for reimbursement. Why couldn’t they get the test at no charge?

We do have a solution in place for members to check out at the pharmacy counter and present their prescription drug ID cards. This allows members get OTC COVID-19 tests at a $0 copay.

However, we have heard that some pharmacies are asking people to pay for the OTC COVID-19 tests up front and submit a claim to their health insurer, along with a copy of the receipt, in order to request reimbursement.

Health plan coverage of OTC COVID-19 tests began nationwide on January 15, 2022. Pharmacies are working to ensure that their systems are able to process these purchases. However, there may be cases where a pharmacy cannot support the use of prescription drug ID cards for people to get the tests at a $0 copay.

If an employee is unable to get a test using their ID card, they can submit a prescription drug claim form, along with a copy of their receipt, to request reimbursement.

Note that we are working to educate pharmacies to ensure that they are able to support this solution and allow members to get OTC COVID-19 tests at a $0 copay.

Are health plans and issuers still required to cover the cost of COVID-19 tests administered with a provider’s involvement or prescription?

Yes.

Is a health plan or issuer required to reimburse for OTC COVID-19 tests purchased prior to January 15, 2022?

No. Plans are not required to provide coverage for OTC tests purchased prior to January 15, 2022 without an order or individualized clinical assessment by a health care provider.

Is a health plan or issuer required to cover the cost of OTC COVID-19 testing that an employer requires as a condition of employment?

No. Health plans are not required to provide coverage of testing for employment purposes.

If tests are purchased in a set (for example, four tests included in a box), does each test included in the set count toward the eight test per month limit?

Yes. The coverage is for eight individual tests per month. If a member purchases a box of four tests, that purchase counts as four tests toward the monthly coverage limit.

Will Prime support paper claims from non-pharmacy retailers?

Yes. Members may submit paper claims from non-pharmacy retailers following the standard paper claims process. Members can submit an Rx claim form and provide their original receipt with their Capital Blue Cross pharmacy benefits.

Members should ensure that the receipt includes the following information:
  • Retailer name.
  • Date.
  • Dollar amount of test(s).
  • Quantity of test(s).
  • Name of test.

Will the dispensing fee coincide with the contracted rate or will it be a flat fee?

For pharmacies in the preferred network, the contractual dispensing fee will be paid, as applicable. Out-of-network providers will not be paid a dispensing fee.

Which specific OTC COVID-19 tests will be covered under the government mandate?

The following FDA-approved test kits are included:

NDC Brand name Tests/pack GPI name
8 tests per 30 days cumulative across Generic Product Identifier (GPI)

56964000000

ELLUME COVID-19 home test

1

COVID-19 at home antigen test kit

11877001140

BINAXNOW COVID-19 AG card home test

2

COVID-19 at home antigen test kit

50021086001

ELLUME COVID-19 home test

1

COVID-19 at home antigen test kit

08337000158

INTELISWAB COVID-19 rapid test

2

COVID-19 at home antigen test kit

14613033968

QUICKVUE at-home COVID-19 test

5

COVID-19 at home antigen test kit

14613033972

QUICKVUE at-home COVID-19 test

2

COVID-19 at home antigen test kit

60006019166

ON/GO COVID-19 antigen self-test

2

COVID-19 at home antigen test kit

82607066026

FLOWFLEX KIT home test

1

COVID-19 at home antigen test kit

82607066027

FLOWFLEX COVID-19 antigen

2

COVID-19 at home antigen test kit

82607066028

FLOWFLEX COVID-19 antigen

5

COVID-19 at home antigen test kit

Please note this listing of covered test kits may change or be expanded in the future as more test are approved or more guidance is issued.

Will there be a control in the system to limit the quantity of tests a member receives?

Yes. There will be a benefit limit of eight individual tests every 30 calendar days per covered member. The system will look back 30 days during adjudication of the claim to determine if the claim is eligible for coverage. There is no early refill threshold. However, we may not be able to cross accumulate deductibles and out-of-pocket maximums for members of groups who use different administrators for their medical and prescription drug benefits.

Are members required to submit a paper claim?

Members with prescription drug coverage through Capital Blue Cross are strongly encouraged to make their OTC COVID-19 test kit purchase at the pharmacy counter so that the pharmacy submits an electronic claim. This will eliminate the need for a member to submit a paper claim. However, members will have to fill out and submit a paper claim with the receipt if they purchase tests online or from a non-pharmacy retailer.

If a member does submit a paper claim, what information do they need to provide?

There are two ways members can get their OTC COVID-19 tests covered through their health plan.

  1. If the member purchased their tests online or not through the pharmacy counter of an in-network pharmacy, they can submit an Rx claim form with their original receipt. 
  2. If the member does not have pharmacy coverage through Capital Blue Cross or purchased their tests through a retailer who is not in our pharmacy network, or doesn’t even have a pharmacy, they will need to save their receipt and submit a claim form for reimbursement. Please note they only need to fill out sections 1, 2, and 7 of the claim form and include their original receipt.
Members should ensure that the receipt includes the following information:
  • Retailer name.
  • Date.
  • Dollar amount of test(s).
  • Quantity of test(s).
  • Name of test.

Some of our employees were not aware that they could make their test purchase at the counter of a contracted pharmacy and have their pharmacy submit an electronic claim. Can they still be reimbursed for that purchase if they submit a paper claim?

Yes. Members can be reimbursed if they submit a paper claim for test kits purchased on or after January 15, 2022, for the duration of the public health emergency, as long as they don’t exceed eight tests over a 30-day period.

Will retail pharmacies be able to ship OTC COVID-19 tests?

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Yes. Most pharmacies will be able to ship COVID home test kits to members, including retail pharmacies, retailers, and online retailers.