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 emergency use authorized 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 emergency use authorized by the FDA (list of authorized tests can be found below) can qualify for reimbursement. Under the new federal guidelines, members can seek reimbursement of up to $12 per test for up to 8 FDA emergency use authorized tests per 30 days per member. That means a family of four can be reimbursed for 32 tests per 30 days for the amount of $12 per test, or the cost of the test if less than $12.

Note: Members should only order/purchase and administer over-the-counter COVID tests based on the manufacturer recommendations.  Please see the manufacturers warnings included on the over-the-counter test packaging for age recommendations.

FDA emergency use authorized tests available for reimbursement:

  • BD Veritor At-Home COVID-19 Test
  • BinaxNOW COVID-19 Antigen Self Test
  • CareStart COVID-19 Antigen Home Test
  • Celltrion DiaTrust COVID-19 Ag Home Test
  • CLINITEST Rapid COVID-19 Antigen Self-Test
  • Ellume COVID-19 Home Test
  • Flowflex COVID-19 Antigen Home Test
  • iHealth COVID-19 Antigen Rapid Test
  • InBios International Inc. SCoV-2 Ag Detect Rapid Self-Test
  • INDICAID COVID-19 Rapid Antigen At-Home Test
  • InteliSwab COVID-19 Rapid Test
  • MaximBio ClearDetect COVID-19 Antigen Home Test
  • OHC COVID-19 Antigen Self Test
  • On/Go COVID-19 Antigen Self-Test
  • QuickVue At-Home OTC COVID-19 Test
  • Rapid SARS-CoV-2 Antigen Test Card
  • Pilot COVID-19 At-Home Test (previously – SD Biosensor, Inc. COVID-19 At-Home Test)
  • Cue COVID-19 Test for Home and Over The Counter (OTC) Use
  • Detect Covid-19 Test
  • Lucira CHECK-IT COVID-19 Test Kit
  • Pixel by Labcorp COVID-19+Flu+RSV Test Home Collection Kit
    *Cost of this test after the $12 reimbursement may be higher than most COVID-19 At-Home tests

In addition, to expand options to access testing, Highmark members can use their existing pharmacy network to receive over-the-counter tests without any up-front costs, eliminating the need for reimbursement (see below for more information on this option).

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 30 days, 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 emergency use authorized 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.

However, beginning April 4, 2022 individuals with Medicare Part B can get up to eight free over-the-counter tests every calendar month through the end of the COVID-19 public health emergency from participating pharmacies or health care providers.

Click here for additional information regarding Medicare over-the-counter test coverage.

Highmark’s Medicare Advantage members can continue to have access to COVID-19 testing at no cost when ordered by a clinician.

Highmark Medicare Advantage members can also receive up to 24 free tests through the federal government website covidtests.gov.

How do I get over-the-counter tests without any out-of-pocket costs?

There are three easy ways to get FREE over-the-counter, at-home COVID-19 tests with no out-of-pocket expense to you:

  1. Government supplied tests via USPS home delivery:
    Every home in the U.S. is eligible to order up to 24 free at-⁠home COVID-⁠19 tests. The tests are completely free. Orders will usually ship in 7-12 days.
    Click here to order your free tests.
  1. Mail order pharmacy – tests delivered directly to your home:
    Members can order tests through Express Scripts® Pharmacy without any upfront costs.
    To order these tests login to the Highmark member portal at the website on the back of your member ID card and click on the pharmacy tab.
    Or, click here to order your free tests – You will be prompted to login to your Express Scripts online account before placing your order.
    If you do not have an Express Scripts online account, click “Register now” and follow the on-screen instructions to setup your account.

Please note that there are currently limited supplies and tests may take up to 4 weeks to arrive.

Note: If you do not have prescription coverage through your Highmark plan, please verify options with your employer.

  1. Pick-up at your local pharmacy:
    Members can visit the same pharmacy where they get their prescriptions filled – or any in-network pharmacy – and follow these easy steps:
  2. Locate one of these 6 FDA emergency use authorized tests approved for distribution with no out of pocket cost to you:
    BD Veritor At-Home COVID-19 Test
    Binaxnow COVID-19 AG Home Test
    CareStart COVID-19 Antigen Home Test
    Celltrion DiaTrust COVID-19 Ag Home Test
    CLINITEST Rapid COVID-19 Antigen Self-Test
    Ellume COVID-19 Home Test
    Flowflex COVID-19 AG Home Test
    iHealth COVID-19 AG Home Test
    INDICAID COVID-19 Rapid Antigen At-Home Test
    Inteliswab COVID-19 Home Test
    On/Go COVID-19 Antigen Self-Test
    Quickvue At-Home COVID-19 Test
    SD Biosensor, Inc. COVID-19 At-Home Test

Note: supplies may be limited, and tests may not be available at all retail pharmacy locations.

  1. Take the test to the pharmacy counter and show your Highmark insurance card to have the test processed through your pharmacy benefit (members with a separate pharmacy benefit card will need to show that).

To locate an in-network pharmacy members can visit the Highmark member website or call the number on the back of their Highmark insurance card or pharmacy benefit card for help.

Note: If you do not have prescription coverage through your Highmark plan, please verify options with your employer.

I purchased FDA authorized over-the-counter COVID-19 tests after January 15th, can I still get reimbursed?

Yes. Just follow the step-by-step instructions found below to submit your claim via mail or through our online member portal.

Note: CHIP members are eligible for reimbursement for tests purchased beginning 8/30/2021.

Note: Beginning on February 14, 2022 members are eligible for a reimbursement amount of $12 per test, or the cost of the test if less than $12.

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
    • Note: CHIP members can seek reimbursement with receipts dated back to 8/30/2021
  • Original or photocopy of 12-digit 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 12-digit UPC (Universal Product Code) from the test box to:

For Highmark New York Members:
Claims
P.O. Box 4208
Buffalo, NY 14240

For All Other Highmark Members:
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 12-digit 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 12-digit 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.**

Why was I only reimbursed $12 per test when I paid more than that for my COVID-19 over-the-counter test?

We encourage members to utilize our preferred pharmacy network to obtain tests at pharmacy locations or through mail order options with no out-of-pocket costs. Any tests purchased otherwise are reimbursed at $12 per test or the cost of the test if less than $12, as required by the federal mandate.