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.
- 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 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. You will need to submit your receipt and properly complete the form in order to receive reimbursement for your 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.
What if I can’t afford to pay for the OTC at-home COVID-19 test(s) upfront?
- 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.
*NEW* (Added 1/18/2022) What if I can’t afford to pay for the OTC at-home COVID-19 tests upfront?
- The federal government has provided access to free COVID-19 tests, which you can order through their dedicated website. Every household in the U.S. is eligible to order at least 4 at-home OTC COVID-19 tests and have them shipped directly to their home.
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.
