What is the Over-the-Counter Test Coverage Mandate?

The Biden Administration announced new federal guidance on Jan. 10, 2022 that people with employer-sponsored or individual health insurance coverage can seek reimbursement for the purchase of FDA approved over-the-counter COVID-19 tests from their employer group or health insurer effective with tests purchased on or after Jan. 15, 2022.

What does the Over-the-Counter Test Coverage Mandate Cover?

Over-the-counter, at-home, diagnostic tests that are approved by the FDA (list of approved tests can be found here) can qualify for reimbursement. Under the new federal guidelines, Highmark members can seek reimbursement for up to 8 FDA approved tests per month per member. That means a family of four can be reimbursed for 32 tests per month.

Note: Tests may be packaged individually or with multiple tests in one package (for example, two tests packaged in one box). Plans are required to cover 8 tests per covered individual per month, regardless of how they are packaged and distributed.

Who is eligible for the over-the-counter test reimbursement?

Highmark members with employer-sponsored or individual health insurance coverage can seek reimbursement for the purchase of FDA approved over-the-counter COVID-19 tests.

Highmark Medicare Advantage members are not eligible for reimbursement at this time.  The Biden Administration did not include Medicare in the coverage requirements and Medicare will not pay for over-the-counter tests through this program. Highmark’s Medicare Advantage members, however, can continue to have access to COVID-19 testing at no cost when ordered by a clinician.

How long will it take to receive my over-the-counter test reimbursement?

Please allow up to 30 days for claims processing and for payment to be issued.

How can I check on the status of my over-the-counter test reimbursement?

Members can access the Member Portal to check their claim status or contact us via the message center if the claim is not yet appearing.  If additional assistance is needed, members can call the customer service number on the back of their member identification card.

What documentation is needed to submit a request for an over-the-counter test reimbursement?

You will need to submit the following documentation, following the instructions below, to receive reimbursement for your over-the-counter test:

  • Completed Member Submitted Health Insurance Claim Form (see below instructions to obtain this form)
  • Itemized receipt for your over-the-counter tests with purchase date on or after 1/15/2022
  • Original or photocopy of UPC (Universal Product Code) label from your purchased over-the-counter tests

Note: If the Member Submitted Health Insurance Claim Form is incomplete or any of the required documentation noted above is not included with your reimbursement request your claim will be rejected with a rejection reason indicating that additional information is needed.

How do I get reimbursed for over-the-counter tests?

NOTE: ** By submitting a manual claim for reimbursement of an over-the-counter COVID-19 test, the member is attesting that the test was purchased for personal use, not for employment purposes, and will not be reimbursed by another source or used for resale **

Mail-in claim reimbursement process:

  1. Log into the Highmark member portal at the website listed on the back of your member ID card
    1. Or click on the form below to open and skip to step 4:
      DOWNLOAD PDF
  2. Under the “Health Care Tools” section, click on “Find Forms”
  3. Click on the arrow to expand the “Medical Forms” section and click on “PDF” under “Member Submitted Health Insurance Claim Form”
  4. Fill out all necessary/required information on the form
  5. Report “COVID OTC Test Reimbursement” in the “Diagnosis or Nature of Illness or Injury” section of the “Member Submitted Health Insurance Claim Form”
  6. Print the “Member Submitted Health Insurance Claim Form”
  7. Sign and date the “Member Submitted Health Insurance Claim Form”
  8. Mail the “Member Submitted Health Insurance Claim Form” along with a dated receipt of purchase and UPC (Universal Product Code) from the test box to:

Claims
P.O. Box 890173
Camp Hill, PA 17089-0173

NOTE:  ** Please submit a separate claim form for each patient.  All expenses for one patient can be submitted with one claim form.**

Digital member portal claim reimbursement process:

  1. Log into the Highmark member portal at the website listed on the back of your member ID card
  2. Under the “Health Care Tools” section, click on “Find Forms”
  3. Click on the arrow to expand the “Medical Forms” section and click on “PDF” under “Member Submitted Health Insurance Claim Form”
  4. Fill out all necessary/required information on the form
  5. Report “COVID OTC Test Reimbursement” in the “Diagnosis or Nature of Illness or Injury” section of the “Member Submitted Health Insurance Claim Form”
  6. Save the “Member Submitted Health Insurance Claim Form” to your computer
  7. Print the “Member Submitted Health Insurance Claim Form”
  8. Sign and date the “Member Submitted Health Insurance Claim Form”
  9. Upload the “Member Submitted Health Insurance Claim Form” along with an image of the dated receipt of purchase and UPC (Universal Product Code) label from the test box, via Message Center on the Member Portal
  10. Click on “Contact Us”
  11. Select your medical plan
  12. Select Message Topic of “Claim Inquiry”
  13. Indicate the inquiry is for “COVID OTC Test Reimbursement”
  14. Click on the Paperclip icon next to “Attach File” and browse to where you saved the “Member Submitted Health Insurance Claim Form” and copies of the receipt and UPC (Universal Product Code) label on your computer
  15. Complete any of the other required fields
  16. Click the “Submit” button

NOTE:  ** Please submit a separate claim form for each patient.  All expenses for one patient can be submitted with one claim form.**