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If you buy eligible tests at the retail pharmacy counter or have them shipped to you from a retail pharmacy, you do not need to submit claims.

If you choose to pay out-of-pocket and buy tests to diagnose a COVID-19 infection outside of the arrangements we make for you, you will need to submit a pharmacy claim form to Prime Therapeutics LLC for reimbursement. You will be reimbursed for the cost of the test or $12 per test, whichever amount is lower.

Yes. Horizon health plans have always covered testing to diagnose a COVID-19 infection when a doctor orders the test.

However, beginning January 15, 2022, for our commercial market members, Horizon health plans will cover up to eight over-the-counter, at-home tests per member every 30 days when the tests are for personal use to diagnose a COVID-19 infection. Members do not need a doctor to prescribe these at-home tests. This coverage will be available through the end of the federal Public Health Emergency (PHE) period.

If you purchase the over-the-counter, at-home tests to test for going to work or to school, for travel or for some other reason not related to illness, then your testing is considered for “surveillance.” These claims are not covered by your health plan.

You can read more about the new guidance from the Biden-Harris Administration online at cms.gov/files/document/11022-faqs-otc-testing-guidance.pdf.

At-home COVID-19 tests that are authorized by the U.S. Food & Drug Administration (FDA) as Over-the-Counter (OTC) are eligible for coverage. These tests are given at home and the results are read at home, without involving a doctor, other health care professional or lab.

Beginning January 15, 2022, you will be able to go to a retail pharmacy and obtain up to eight tests at the pharmacy counter without member cost sharing when the tests will be used to diagnose a COVID-19 infection. In addition, many pharmacies, including retail, can ship over-the-counter, at-home COVID-19 test kits to you. Please note that tests often come in packages of two tests; in those instances, you can get four packages.

Regardless of how you get your tests — retail or online — every eligible member, including your spouse and dependents if they are enrolled through your plan, will be eligible to get up to eight tests per member every 30 days. However, due to supply and demand, pharmacies and online retailers may limit the number of tests you can buy at one time.

Any test purchased for surveillance purposes (for example, testing required to go to work or school, for travel or for some other reason not related to illness) is not covered by insurance.

Yes, Medicare Advantage and Medicaid members do not have this exact coverage.

Medicare Advantage plans cover COVID-19 testing when ordered by a doctor. Medicare Advantage members also have access to free at-home tests at community health centers and Medicare-certified health clinics. Up to 50 million of these tests are provided by the U.S. Department of Health & Human Services at no cost. You can learn more about this program at hrsa.gov/coronavirus/testing-supplies.

Medicaid plans already cover at-home COVID-19 testing at no cost. The State of New Jersey will soon implement a new coverage requirement for Medicaid members to cover over-the-counter, at-home COVID-19 testing.

Members enrolled in Commercial market health plans have this new coverage beginning January 15, 2022. The coverage requirement applies to members enrolled in fully insured and self-insured health plans.

Horizon will administer the coverage for fully insured and self-insured health plans that have prescription drug benefits with us through our pharmacy benefits manager (PBM), Prime Therapeutics LLC.

Fully insured and self-insured health plans that carve out their pharmacy benefit to a different PBM will need to work with their PBM to administer these benefits to their members, although some exceptions may apply.

This coverage requirement also applies to members enrolled through the Federal Employee Program (FEP). FEP members must submit a paper health benefits claim form with their receipts to their local BCBS Plan for reimbursement. The contract holder will receive a check in the mail after the claim is processed. Instructions on how to submit claims are available.

If you need to be tested because you have symptoms, or because you were exposed to someone who has COVID-19, then your testing is considered “diagnostic.” You are being tested to diagnose an infection. Claims for diagnostic testing are covered by your insurance with no out-of-pocket costs.

If you need to be tested to go to work or school, for travel or for some other reason not related to illness, then your testing is considered for “surveillance.” These claims are not covered by insurance.

This requirement is effective January 15, 2022. At-home tests purchased before January 15, 2022 are not covered unless the tests were ordered by a doctor to diagnose a COVID-19 infection.