Over-The-Counter (OTC) COVID-19 Tests Covered

Per guidance issued by the Federal Government on January 10, 2022, PRISMHealth will provide coverage for diagnostic at-home COVID-19 tests for personal use that were purchased on or after January 15, 2022.  Diagnostic tests are performed if covered individuals are experiencing COVID-19 symptoms or have been recently exposed.

Coverage will continue until the end of the public health emergency and will be provided without cost-sharing, a healthcare provider order, medical management, or prior authorization for enrolled participants of all plans.  To be eligible, tests must be purchased by the participant for personal use and not for employment screening purposes.

Individuals enrolled in plans with ESI Rx have the opportunity to either purchase tests out-of-pocket and submit a claim form to the health plan to obtain reimbursement or they may secure tests directly from network pharmacy outlets at no cost and without the need to submit a claim form.

Plans with carrier direct Rx can obtain reimbursement for tests purchased out-of-pocket by submitting a claim form to their respective PRISMHealth carrier partner (Anthem, Blue Shield, or Kaiser).

Participants are eligible to receive coverage for up to eight FDA approved OTC COVID-19 at-home tests per covered individual in the household per calendar month.  Each test is counted separately toward the quantity limit even if multiple tests are sold in a single package; meaning if one package includes two tests, that package will count as two tests.  PRISMHealth plans will also continue to cover COVID-19 tests that have been ordered by healthcare providers and those tests will not count against this quantity limit.

Reimbursement process

To be reimbursed for at-home test purchased out-of-pocket, members can submit a Claim Form and proof of purchase receipt to their respective carrier. The proof of purchase/receipt should include the name of the retailer, the street address (or if purchased online the website address), date of purchase, UPC code, and cost.  Participants will be reimbursed in full for the test and applicable sales tax; shipping and handling charges are not eligible.

We will continue to monitor the landscape and keep you apprised of any developments.  Thank you.  Feel free to contact me if you have questions or would like additional information.

Additional resources

Anthem

To locate a test site, click here

Logon at  www.anthem.com/ca to submit a claim

Blue Shield

For more information, visit “Coverage for COVID-19 testing”

Visit “How to file a claim for COVID-19 test reimbursement” to submit a claim 

Kaiser

Submit a claim

Visit kp.org/coronavirus for local updates

Federal

HHS – OTC tests

CMS – OTC tests

COVIDTests.gov