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COVID-19 Updates: February 28, 2022

Feb 28, 2022
Blog, Clinical News, COVID-19

***Updated***New Coverage Requirements for Over-the-Counter (OTC) COVID-19 Tests Go into Effect January 15, 2022

On January 10, the federal government announced a new requirement for health plans to cover the cost of over-the-counter (OTC) at-home COVID-19 tests under certain circumstances. Based on this new requirement, your health plan will cover OTC at-home COVID-19 tests starting January 15, so you will be able to get them covered by your health plan without a prescription.

What does this mean for me?
  • Starting January 15, you will be able to go to a pharmacy in your network, pick up an OTC at-home COVID-19 test, and either:
    • Have the pharmacy bill the test to MaxorPlus (which administers your health plan’s pharmacy benefit), or
    • Pay for the test upfront and manually submit a claim to be reimbursed.
How do I get a free OTC at-home COVID-19 test?
  • To get your OTC at-home COVID-19 tests for free – go to a pharmacy in your network, pick up the test from the shelf, and bring it to the pharmacy counter and request that the pharmacy submit a claim to your health plan for the test. Multiple pharmacies have currently accepted this process including CVS, Walmart, Sam’s Club, Rite Aid, and multiple independents – however all pharmacies in your network are included.
  • If your provider writes a prescription for the OTC at-home COVID-19 test kit to be filled at your in-network pharmacy, this will also be available at no cost.
  • The test will either be $0 directly through your pharmacy, or by reimbursement if you are charged for your test. Be sure to SAVE YOUR RECEIPT if you need to submit a claim to MaxorPlus for reimbursement.
Will I have to pay for my OTC at-home COVID-19 test up front?
  • No, if you use an in-network pharmacy, and go to the pharmacy counter to have the pharmacy submit a claim to your health plan – your copay will be $0 directly through the pharmacy. This will be processed like a prescription so you may have to wait, however it will be at no cost to you.
  • A pharmacy may ask you to pay out of pocket, though. If you do so, please SAVE YOUR RECEIPT. You will be able to submit this receipt to MaxorPlus for reimbursement.
How will I be reimbursed for an OTC at-home COVID-19 test if I purchase the test upfront and then submit a claim for reimbursement to MaxorPlus?
  • If you use an in-network pharmacy, you can obtain a test with no out-of-pocket expense, if you go to the pharmacy counter and the pharmacy processes a claim through your insurance. If you purchase a product at the register without asking the pharmacy to submit a claim to your health plan, you will be charged the full price from that pharmacy. SAVE YOUR RECEIPT. If you properly fill out a claim form, located here (***NEW***), and submit your receipt to MaxorPlus, you will be reimbursed through your health plan.
  • If you use an out-of-network pharmacy, you will have to pay for the test upfront. SAVE YOUR RECEIPT to submit to MaxorPlus for reimbursement. If you need to get reimbursed, you may submit your claim to MaxorPlus by downloading and completing our Member Reimbursement Form, located here (***NEW***).  You will need to submit your receipt and properly complete the form in order to receive reimbursement for your test. You may have an out of pocket cost and ONLY be reimbursed up to $12 per test when using an out-of-network pharmacy or non-pharmacy location.
***NEW*** Can I purchase an OTC at-home COVID-19 test that costs more than $12?
  • Yes, if you get an FDA-authorized tests at an in-network pharmacy, and go to pharmacy counter to have them process your claims, you won’t need to pay anything out-of-pocket. At any other location, you may purchase an FDA-authorized test, but you will only be reimbursed at a maximum of $12 per test
Is there a limit on how many OTC at-home COVID-19 tests are to be covered at a time?
  • Yes. Your health plan will cover up to 8 OTC at-home COVID-19 tests per covered individual per month. You may purchase more, but you will have to pay for the full cost of those tests.
***NEW*** Which OTC at-home COVID-19 tests are part of this program?
  • Any FDA-authorized or approved test is covered as part of the program. Typically, FDA-authorization is shown on the test packaging.
***NEW*** Do I need to get a doctor’s prescription for reimbursement for an OTC at-home COVID-19 test?
  • No
***NEW*** How long will it take to receive my reimbursement?
  • Typically, reimbursement may take up to 20 days. To help avoid delays, it’s a good idea to make sure you complete all requested information.
What if I can’t afford to pay for the OTC at-home COVID-19 test(s) upfront?
  • The federal government has provided access to free COVID tests through their dedicated website, covidtests.gov. Every household is the U.S. is eligible to order 4 free at-home OTC COVID tests and have them shipped to their home.
  • Your plan allows for you to get a free OTC at-home COVID-19 test if you get the test at an in-network pharmacy, go to the pharmacy counter, and ask for them to submit a claim to MaxorPlus.
  • You can also access free testing in your community. A list of community-based testing sites can be found here. COVID-19 tests are also available without cost-sharing to covered individuals when administered by a healthcare provider like a nurse, doctor, or pharmacist, without limitation.
What if I already bought and paid for OTC at-home COVID-19 test? Can I still get reimbursement for those?
  • Your health plan will cover OTC at-home COVID-19 tests purchased on or after January 15, 2022. You cannot seek reimbursement for any test kits purchased before January 15, 2022.
This new coverage requirement does not apply to tests purchased for employment purposes. Also, in general, tests have to be approved by the U.S. Food & Drug Administration (FDA) to be eligible for reimbursement under this coverage requirement. Other restrictions may apply.