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 eight free at-home COVID-19 tests.

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.

You may wish to check with your prescription drug benefit provider to determine how they are covering the cost of tests.

If a member’s prescription drug benefit does not cover OTC COVID-19 tests, we can cover the 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 (with sections 1, 2, and 7 completed) and receipt. The receipt should include the purchase date, test name, dollar amount, and retailer name.

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.

My organization has prescription drug coverage through Capital Blue Cross. Are there any direct-to consumer options my employees can use to get COVID-19 tests online at no cost?

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Yes, your employees can use one of these suppliers to take advantage for direct-to-consumer shipping of at-home COVID-19 tests: Express Scripts® Pharmacy or Thrifty White Pharmacy. If they use these suppliers and supply their member ID information, they will not be required to pay in advance and submit a claim for reimbursement.

Express Scripts® Pharmacy

  • To order, log in to Express Scripts online. If you do not have an account, you can create one using the ID information on your ID card.
  • Express Scripts offers an “Order At-Home COVID Tests” option.

Thrifty White Pharmacy

  • Visit Thrifty White’s Online Drugstore to set up an account by providing your date of birth and health plan ID number on your ID card.
  • Place your order for FlowFlex COVID-19 tests. Enter PT22Flow as your coupon code to ensure your COVID-19 test order is processed at no charge.

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.

Please note that we are not able to reimburse paper claims for test kits purchased from individuals or from resellers such as eBay, Craigslist, and Facebook Marketplace.

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 OTC COVID-19 tests will be covered?

Any OTC COVID-19 test authorized by the U.S. Food and Drug Administration is eligible for coverage.

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.

Please note that we are not able to reimburse paper claims for test kits purchased from individuals or from resellers such as eBay, Craigslist, and Facebook Marketplace.

If a member with Capital Blue Cross pharmacy benefits submits a paper claim, what information do they need to provide?

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. The receipt should include the purchase date, test name, dollar amount, and retailer name.

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.