Coverage of Over-the-Counter (OTC) COVID-19 Tests for Members

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will cover over-the-counter (OTC) COVID-19 tests that have been approved or received emergency use authorization (EUA) by the FDA beginning on January 15, 2022, and continuing 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.

Blue Cross NC is partnering with Prime Therapeutics (Prime), our pharmacy benefits manager (PBM), to cover the cost of up to eight (8) OTC COVID-19 tests per covered member per month.

Please see below for details on purchasing, reimbursement and eligibility.

Purchasing OTC COVID-19 Tests  

• Blue Cross NC encourages members to get their eligible OTC COVID test from an in-network pharmacy and present their insurance card, the same way they purchase their prescriptions. By purchasing at 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 eligible 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 at an out-of-network pharmacy or location other than a pharmacy counter.

Reimbursement 

• 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. 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 OTC COVID-19 tests per month for reimbursement. 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:
  • Completed OTC COVID-19 test claim form
  • Purchase receipt documenting the date of purchase and the price of the test
  • The test’s UPC code
• The address to mail the OTC COVID-19 test claim form 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.

Eligibility 

• 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.

More information about COVID-19 testing and resources for our members can be found at our COVID-19 page.