COVID-19 FAQs

You have questions about COVID-19,
we are here to answer them.

Frequently Asked Questions

General

Where can I get more information?

Will patients be balance billed if they see an out-of-network provider?

Current federal regulations prohibit any provider from balance billing patients for the COVID-19 vaccine.

Who can members contact if they have questions or concerns about a claim?

If members have specific questions about coverage, we encourage them to contact Customer Service through Blue Connect or by using the number on the back of their insurance card.


Vaccines

How much will it cost me to get a COVID-19 vaccine?

We are covering COVID-19 vaccines and boosters that are FDA approved, including for emergency use authorization (EUA), at no cost for all members, both during the public health emergency and after.

The federal government covers, at no member cost-share, both the vaccine and the administration fee in 2021 for traditional Medicare and Medicare Advantage members.

For members on a commercial plan, the federal government covers the vaccine costs during the public health emergency. Blue Cross NC (or the ASO group, for customers on those plans) covers the cost of vaccine administration fees. After the public health emergency, Blue Cross NC and ASO groups are required to cover the cost for the vaccine and administration costs at 100% for in-network providers.

Are vaccines covered when given at a retail pharmacy?

COVID-19 vaccines given at pharmacies are covered for Blue Cross NC members, with no member cost share.

Will coverage be the same for Blue Cross NC members who receive the vaccine outside of North Carolina?

For Blue Cross NC members living or traveling outside of North Carolina, the federal government covers the cost of the vaccine and Blue Cross NC (or the ASO group, for customers on those plans) covers the cost of administration fees during the public health emergency. After the public health emergency, the cost of the vaccine and administrative fees are covered as preventative services and reimbursement will depend on whether the provider is in network or out-of-network.

Will Administrative Services Only (ASO) groups be required to cover vaccine costs?

The applicable federal regulations state that the health benefit plan or insurer must cover the admin fee at 100%. This is a temporary benefit change that applies to all plans under federal law during the public health emergency, with the federal government paying the cost of the vaccine, and ASO groups to cover administration costs the same for both INN and OON providers during that time. After the public health emergency, ASO groups are required to cover the cost for the vaccine and administration costs at 100% for in-network providers.

Are the COVID-19 vaccines effective?

The CDC shared data showing that vaccines continue to be remarkably effective in reducing risk of severe disease, hospitalization, and death, even against the Delta variant.

According to the latest data from North Carolina hospitals, 91% of all COVID patients and 96% of all COVID ICU patients were unvaccinated. Bottom line is that vaccines save lives. More than 11 million doses of the COVID-19 vaccine have been administered in North Carolina.

What should I do after I receive the vaccine?

Everyone should continue to wear a mask indoors and in public places where social distancing is not possible, even if masks are not mandated. Learn more about current CDC mask recommendations and requirements here.

Updated Guidance from NCDHHS includes:

  • Updated Guidance for Events and Festivals and CDC Large Gatherings Planning Toolkit for Health Departments
  • Updated Pfizer/Moderna and J&J)

Who is eligible to get the vaccine?

Anyone age 5 and older is now eligible for the COVID-19 vaccine.

North Carolinians should refer to the North Carolina Department of Health and Human Services (NCDHHS) for information on when children below the age of 12 will become eligible for the vaccine.

Where can I get the vaccine?

Find your spot using the vaccine location tool provided by NCDHHS.

Members who live outside of North Carolina will need to follow their local and state guidelines to determine where they should get the vaccine.

Federal Employee Plan (FEP) members should use FEP’s vaccine network to locate a participating retail pharmacy.

Looking for a COVID-19 vaccine for someone who is at home because of limited mobility? You can find at-home vaccine providers here.

Do I need an additional dose of the COVID-19 vaccine?

Booster shots are now available for individuals who have been fully vaccinated.

Individuals who received both doses of the Pfizer or Moderna vaccine more than six months ago are eligible for a booster shot if they fall within one of the below groups:

  • Age 65 and older
  • Age 18 – 64 and at high risk of severe COVID-19
  • Age 18 – 64 and work in a high-risk setting, for example healthcare workers, teachers, childcare providers or food employees

Individuals 18 and older who received the Johnson & Johnson vaccine more than two months ago are eligible for a booster shot.

Details on COVID-19 booster shot eligibility and guidance on booster shots, including mix-and-match options, can be found on the CDC website.

The North Carolina Department of Health and Human Services (NCDHHS) encourages individuals to speak with a doctor, nurse or pharmacist if they have questions about what booster is right for them.

Visit myspot.nc.gov for the most up-to-date information about the COVID-19 vaccines. As new guidance is released from the Centers for Disease Control and Prevention (CDC) and other public health authorities, Blue Cross NC will update communications on COVID-19 vaccines and boosters. For more information, visit https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html.

Is my child eligible to get the COVID-19 vaccine?

Children ages 5 and up are now eligible to receive the Pfizer vaccine.

Whether you vaccinate your kids is a personal choice. However, getting vaccinated is an important step in stopping the pandemic for both kids and adults. Check out our recent blog post to learn more about what to expect when your child gets vaccinated.

Children are vulnerable to the COVID-19 virus just like everyone else. According to NCDHHS, cases of COVID-19 among children in the U.S. rose approximately 240% during the most recent surge, demonstrating a need to protect children from the disease.

Are COVID-19 vaccines safe for kids and teens?

Yes. The CDC and the FDA have determined that COVID-19 vaccines are safe and effective for this age group. Scientists are continuing to monitor safety in adolescents.

According to the FDA, the COVID-19 vaccine is safe and effective. There were no safety concerns or serious side effects noted in the clinical trials and ongoing study

Where can my child get vaccinated?

The vaccine is widely available across the state. Children ages 5 to 11 can get vaccinated at any location that has the smaller dose of Pfizer available, including at their pediatrician or doctor’s office, hospitals, local pharmacies and grocery stores.

There are hundreds of locations in North Carolina that carry Pfizer for 5 to 11-year-olds, and NCDHHS set up family vaccination sites across the state so that every child has a spot to take their shot.

To find a vaccine for children ages 5-11, visit covid19.ncdhhs.gov/vaccines.

Is there a cost to vaccinate my child?

No, there is no cost to vaccinate your child. COVID-19 vaccines are provided without any out-of-pocket cost to you, regardless of insurance and immigration status. The only thing required is parental consent.

Will my child experience side effects from the COVID-19 vaccine?

According to NCDHHS, there may be temporary and minimal side effects. Children may experience a sore arm and feeling tired or achy for a day or two. NCDHHS further notes the risks of serious side effects from the vaccine are far less than the risk of serious illness from COVID-19.

Up-to-date information and resources for Blue Cross NC members can be found at bluecrossnc.com/covid-19/vaccine-information/covid-19-vaccines-children.

Should I get vaccinated if I am pregnant, breastfeeding or plan to become pregnant?

Yes. The CDC recommends anyone over the age of 12 should receive the vaccine, including those who are pregnant, plan to become pregnant or breastfeeding.

According to the CDC, the vaccine is safe to receive during your pregnancy. It is one of the best ways to protect yourself and your baby since pregnant women are at an increased risk for severe illness from COVID-19. The CDC further notes that for women who are breastfeeding, the vaccine is safe and can pass along COVID-19 antibodies to your breastfeeding child, providing them with further protection from the virus.

If you have additional questions about protecting your newborn from COVID-19, consult your pediatrician. Guidelines and recommendations are constantly changing, and they can ensure you’re practicing the latest.


Testing

Where can I get a COVID-19 test?

North Carolina residents can find a number of COVID-19 testing options, including more information about OTC COVID-19 testing, at ncdhhs.gov/GetTested. To find a testing location outside of North Carolina, visit https://www.hhs.gov/coronavirus/community-based-testing-sites/index.html.

When should I get tested?

We encourage members to speak to their primary care provider, pharmacist, or refer to this NCDHHS website if they have questions about COVID-19 testing.

How much will it cost me to get a COVID-19 test?

Health plans and issuers are required to cover at no cost-share to members (copayments, deductibles and coinsurance), COVID-19 testing methods performed in labs or at-home when ordered by a provider, are consistent with current CDC guidance and have been cleared, approved or given emergency use authorization (EUA) by the FDA. With new federal requirements put in place to expand access to COVID-19 tests, Blue Cross NC will cover over-the-counter (OTC) tests that have been approved or received emergency use authorization (EUA) by the FDA, beginning on January 15, 2022, and continue through the public health emergency. These OTC tests do not have to be ordered by a doctor and can be self-administered and self-read at home.

Depending on where you purchase your OTC test, you will pay no out-of-pocket costs or pay and be reimbursed.

We encourage members to get their OTC COVID test from an in-network pharmacy and present their insurance card, the same way they purchase their prescriptions. By purchasing from an in-network pharmacy counter, insurance is filed electronically, allowing members to purchase the test with no out-of-pocket costs.

Members can also pay out of pocket and mail an OTC COVID-19 test claim form to our pharmacy benefit manager, Prime, for reimbursement. This applies to members who purchase OTC tests without their Blue Cross NC prescription drug card or at a location other than a pharmacy counter.

Most Blue Cross NC members should not need reimbursement for their OTC COVID-19 tests. If members present their Blue Cross NC member ID card at an in-network pharmacy counter, they will pay no out-of-pocket costs.

Reimbursement for test kits purchased from out-of-network pharmacies and retailers (any location other than a pharmacy counter) is limited to no more than $12 per individual test.

Pursuant to COVID-19-related legislation and regulations, Blue Cross NC will continue waiving member cost-sharing (copays, deductibles and coinsurance) for COVID-19-related provider screening visits and testing until the public health emergency is over.

COVID-19 tests for general workplace health and safety (such as employee “return to work” programs) are not required to be covered.

We encourage members to speak to their primary care provider, pharmacist, or refer to this NCDHHS website if they have questions about COVID-19 testing.

Is prior authorization required for COVID-19 testing?

COVID-19 tests, including over-the-counter (OTC) tests, do not need prior approval. That means your doctor doesn’t need to ask us for approval before you’re tested for COVID-19.

Will I be reimbursed for my OTC COVID-19 test?

Most Blue Cross NC members should not need reimbursement for their OTC COVID-19 tests. If members present their Blue Cross NC member ID card at an in-network pharmacy counter, they will pay no out-of-pocket costs.

Any member who purchases OTC tests without their Blue Cross NC prescription drug card or at a location other than a pharmacy counter can pay out of pocket and mail an OTC COVID-19 test claim form to our pharmacy benefit manager, Prime, for reimbursement.

Reimbursement for test kits purchased from out-of-network pharmacies and retailers (any location other than a pharmacy counter) is limited to no more than $12 per individual test. To be reimbursed for an OTC COVID-19 test, the test must be approved or have emergency use authorization (EUA) by the FDA.

Members are eligible to receive up to eight (8) OTC COVID-19 tests per month. Each test is counted separately regardless of how many tests are sold in one package.

When submitting a claim to be reimbursed, members must mail a:

The address to mail the OTC COVID-19 Test paper claim is:

Prime Therapeutics
Mail route: Commercial
PO Box 25136
Lehigh Valley, PA 18002-5136

Upon receipt of the required materials, pharmacy benefits manager Prime will issue a check reimbursing the member. The standard turnaround time for reimbursement is 21 days. Depending on volume, additional time may be needed to process reimbursement requests. Purchasing the tests through your pharmacy will eliminate the need for reimbursement.

COVID-19 tests for general workplace health and safety (such as employee “return to work” programs) are not required to be covered.

*Note: A pharmacist signature and pharmacist NPI number are NOT required on the claim form.  However, the member MUST sign the form attesting that the test kits are not being used for testing required by their employer, return to work, travel, attending recreational events, and will not be resold.

Do I have to purchase an OTC test from a specific retailer to be reimbursed?

No. OTC COVID-19 tests that have been approved or received emergency use authorization (EUA) by the FDA are covered regardless of where you purchase them.

We encourage members to get their OTC COVID test from an in-network pharmacy and present their insurance card, the same way they purchase their prescriptions. By purchasing from an in-network pharmacy counter, insurance is filed electronically, allowing members to purchase the test with no out-of-pocket costs. Members can also purchase OTC tests at a location other than a pharmacy counter. When purchasing an OTC test from an out-of-network pharmacy or retailer, members are required to pay out of pocket and mail an OTC COVID-19 test claim form to our pharmacy benefit manager, Prime, for reimbursement.

Prime’s preferred network for the COVID test kits is not limited to a particular chain. OTC COVID tests will be available through pharmacies (in-network or out-of-network) and retailers (any location other than a pharmacy counter).

If I don’t want to pay any up-front out-of-pocket costs for my OTC test, which pharmacies can I use? Click here to search for a pharmacy in Prime’s preferred network.

Will all members be eligible for OTC test coverage?

OTC testing coverage applies to members of Blue Cross NC’s fully-insured (individual and group), Administrative Services Only (ASO) group health plans and the Federal Employee Plan (FEP).

The requirements do not apply to Medicare plans, excepted benefits (such as stand-alone vision or dental) or retiree-only plans.

If the back of your Blue Cross NC ID card doesn’t list Prime as your prescription drug plan, you may have a different pharmacy benefit manager. If this is the case, please ask your employer or benefits manager about your OTC testing reimbursement options.

COVID-19 tests for general workplace health and safety (such as employee “return to work” programs) are not required to be covered.

Members should contact the Blue plan listed on their ID card for information about their COVID-19 benefits.

Will FEP cover OTC COVID-19 tests?

Yes. FEP will cover member submitted claims at zero cost share for COVID-19 tests with emergency use authorization available over the counter (OTC) without a physician order through the medical benefit. Member submitted claims must include a copy of an itemized receipt indicating the specific testing performed. For more information, visit https://www.fepblue.org/.

How can I determine if an OTC test is FDA approved?

For the most updated information on tests that have emergency use authorization from the FDA to test for COVID-19, visit the FDA website: Individual EUAs for Antigen Diagnostic Tests for SARS-CoV-2 and search “OTC.”

How do I use an OTC COVID-19 test?

For general guidance on using at-home tests, including OTC tests, and what to do after you have your result, please review the At-Home Testing Guidance for the General Public (Spanish) from NCDHHS.

Will Blue Cross NC cover the full cost of all OTC tests, or will they only reimburse a certain dollar amount per test?

Blue Cross NC will cover OTC tests that have been approved or received emergency use authorization (EUA) by the FDA. Members are eligible to receive up to eight (8) OTC COVID-19 tests per month. Each test is counted separately regardless of how many tests are sold in one package.

If members present their Blue Cross NC member ID card at an in-network pharmacy counter, they will pay no out-of-pocket costs. Reimbursement for test kits received from out-of-network pharmacies and retailers (any location other than a pharmacy counter) is limited to no more than $12 per individual test.

Does the OTC testing quantity impact my ability to have a test covered that is ordered by a health care provider?

While members are only eligible to receive coverage for eight (8) OTC tests each month, Blue Cross NC will continue to cover at no cost-share to members (copayments, deductibles and coinsurance), COVID-19 testing methods performed in labs or at-home when ordered by a provider, are consistent with current CDC guidance and have been cleared, approved or given emergency use authorization (EUA) by the FDA.

Can I mail a paper claim to Blue Cross NC?

No. The address to mail the OTC COVID-19 test claim is:

Prime Therapeutics
Mail route: Commercial
PO Box 25136
Lehigh Valley, PA 18002-5136

Upon receipt of the required materials, pharmacy benefits manager Prime will issue a check reimbursing the member. The standard turnaround time for reimbursement is 21 days. Depending on volume, additional time may be needed to process reimbursement requests. Purchasing the tests through your pharmacy will eliminate the need for reimbursement.

Why did my paper claim get returned?

You must complete the correct OTC COVID-19 test claim form and mail to Prime at:

Prime Therapeutics
Mail route: Commercial
PO Box 25136
Lehigh Valley, PA 18002-5136

Upon receipt of the required materials, pharmacy benefits manager Prime will issue a check reimbursing the member. The standard turnaround time for reimbursement is 21 days. Depending on volume, additional time may be needed to process reimbursement requests. Purchasing the tests through your pharmacy will eliminate the need for reimbursement.

What is the timing to be reimbursed for OTC tests?

The standard turnaround time for reimbursement is 21 days. Depending on volume, additional time may be needed to process reimbursement requests. Purchasing the tests through your pharmacy will eliminate the need for reimbursement.

Are OTC tests covered for members under their medical benefits?

For Blue Cross NC’s fully-insured (individual and group) and Administrative Services Only (ASO) group health plans, Blue Cross NC will cover this under its prescription drug plan, which is administered by Prime.

If the back of the member's Blue Cross NC ID card doesn’t list Prime as its prescription drug plan, the member may have a different pharmacy benefit manager. If this is the case, members should ask their employer or benefits manager about their OTC testing reimbursement options.

For Federal Employee Plan (FEP) members, FEP will cover this under their medical plan. Members must submit their claim for reimbursement along with a copy of an itemized receipt indicating the specific testing performed.

This coverage requirement doesn't apply to Medicare plans at this time.

Who should I contact if I suspect unethical business practices?

To report price gouging, visit https://ncdoj.gov/file-a-complaint/price-gouging/. To report suspected fraud, waste or abuse, contact Blue Cross NC at SIU@bcbsnc.com or (800) 324-4963. or (800) 324-4963.


Continued Care and Telehealth

How is telehealth covered?

Blue Cross NC will cover all telehealth visits at the same cost as face-to-face visits through March 31, 2022. This means, what you normally pay when you visit a doctor in-office is what you’ll pay for a telehealth visit.

How do I know if my provider offers telehealth?

Virtual (or telehealth) visits can be used with your primary care doctors, specialists, and behavioral health providers. Or any licensed NC provider who can provide telehealth services. Call your doctor before going into the office to see if telehealth is available.


Providers

Are there differences in coding for different segments?

For Traditional Medicare and Medicare Advantage members: During the Public health emergency, providers should file claims related to the vaccine and administration of the vaccine directly to Traditional Medicare. If providers file vaccine-related Medicare claims with Blue Cross Blue Shield of North Carolina (Blue Cross NC) during the emergency, the system will deny the claim and recommend that the provider file with Traditional Medicare for Medicare Advantage members.

For customers on a grandfathered group plan, vaccines will be available at no member cost-share. Blue Cross NC and Administrative Services Only (ASO) groups will cover vaccine administration fees during the public health emergency. For grandfathered plans, providers should submit claims to Blue Cross NC.

For all other member segments: Providers should follow the coding below and submit claims to Blue Cross NC as usual.

For commercial members, retail pharmacies are able to file all vaccine claims under the medical or pharmacy benefits for commercial members.

Where can I find the latest information for providers?

Read our latest provider news updates here or contact the Provider Blue Line at 800-214-4844 from 8:00AM – 5:00PM, Monday – Thursday and 8:00AM – 4:00PM on Fridays.

Providers will need to direct all claim inquiries to Provider Service by calling 1-800-214-4844.

How do providers code the vaccine?

The American Medical Association (AMA) has provided this table to link the COVID-19 vaccine product codes to their associated immunization administration codes, manufacturer name, vaccine name(s), 10 and 11-digit National Drug Code (NDC) Labeler Product ID, and interval between doses. These codes are also located in the Medicine section of the CPT code set.


Treatment

If I am treated for COVID-19, what will I be responsible for paying?

COVID-19 treatments are covered based on each individual’s insurance plan, and members may be responsible for a portion of their treatment costs to include copayments, coinsurance and deductible amounts. We continue to closely monitor and re-evaluate policies to best serve our customers and communities.

For Medicare Advantage plans offered or administered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC), the COVID-19 treatment cost-sharing waiver will remain in place through December 31, 2021.

What treatment options are available?

According to the CDC, treatments used for COVID-19 should be prescribed by your healthcare provider. For the most up-to-date information on COVID-19 treatment, visit cdc.gov/coronavirus/2019-ncov/your-health/treatments-for-severe-illness.html.

Up-to-date information and resources for our members can be found at BlueCrossNC.com/Coronavirus.