At-Home COVID-19 Test Kits FAQ
Effective January 15, 2022, commercial insurers and plan sponsors are required to cover the cost of over-the-counter, at-home COVID-19 tests (8 tests every 30 days per member), for personal use that are not paid by other sources. This requirement is effective while the federal Public Health Emergency is in place. PacificSource has created the following FAQ to address concerns and questions. We will continue to monitor the situation and make adjustments as necessary.
Understanding the process
Through our pharmacy benefit manager, CVS Caremark, members enrolled through their employers or those with an individual or family plan can now obtain at-home COVID-19 tests at $0 member cost share at participating pharmacies, subject to available supplies. For information about how this applies to Medicare and Medicaid members, please scroll to the bottom of this FAQ.
Eligible members may receive up to 8 at-home COVID-19 tests every 30 days without a prescription. Please note that some at-home COVID-19 test packages include multiple tests; the number of individual tests in the box will be counted toward the 8 test maximum.
Important: To be covered in full, with a $0 cost share, members must use an in-network pharmacy. An in-network pharmacy can include an online participating pharmacy. Members will need to have their member ID card available to process the $0 transaction.
Please note: Pharmacies (even in-network) may opt out of processing claims for the tests through CVS Caremark, which would result in an out-of-pocket expense for the member. Please check with your local pharmacy to ensure they are participating.
See information specific to CVS Pharmacy below.
Members who choose to buy at-home COVID-19 tests at a nonparticipating pharmacy, retailer, or online retailer will need to submit a request for reimbursement through Caremark.com. (Find instructions here.) The maximum allowable for reimbursement at nonparticipating providers is $12 per test or the actual cost of the test, whichever is less.
To be covered through the pharmacy benefit at $0 copay, only specific FDA-approved COVID tests are eligible. For a current list, see our Find-a-Drug page.
For those who chose to self-pay and seek reimbursement, any FDA-approved at-home COVID test is eligible.
Members are advised to first check to see if the pharmacy is participating in the zero-cost at-home test program. To be covered in full, with no member cost share, members must use an in-network pharmacy and go to the pharmacy window to request the tests and present their member ID card. If members purchase through a nonparticipating pharmacy, retailer or online retailer, they will need to submit for reimbursement through Caremark.com. The reimbursement rate for at-home COVID-19 tests will be $12 per test, or the actual cost of the test, whichever is less.
If a member purchases the tests from a participating pharmacy and goes through the front checkout register, this will be considered an out-of-network purchase and subject to the $12 maximum allowable reimbursement of the actual cost of the test, whichever is less.
Most in-network pharmacies are participating in this program; however, pharmacies may opt out of processing claims for the tests through your pharmacy benefit. If this is the case, and the member submits a claims for reimbursement, the purchase will be subject to the $12 maximum allowable reimbursement, or the actual cost of the test, whichever of less.
Are you a member through Medicare or Medicaid? Scroll toward the bottom of this FAQ to read how $0 test kit availability applies to Medicare and Medicaid members.
CVS Pharmacy
PacificSource members have access to $0 at-home COVID-19 tests at their local CVS Pharmacy. Members have two ways to get their at-home COVID-19 tests through a CVS Pharmacy:
1. Online ordering for an in-store pick up
Online ordering is available at CVS.com (or through CVS Pharmacy app). At this time, ordering online requires an in-store pick up.
To locate the closest CVS pharmacy with OTC at-home COVID-19 test inventory,
click COVID-19 OTC tests and enter your zip code. Next, select OTC tests and enter your member ID information (such as BIN, PCN, Group Member ID). Members will receive a confirmation of OTC test availability, and within an hour, be able to pick up their tests at the front of the store. Orders not picked up within 72 hours will be canceled. Drive-through pick up is unavailable.
2. Visiting a CVS Pharmacy
Members can visit their local CVS Pharmacy and get their zero-cost tests through the pharmacy window (not at the front checkout).
Because this no-cost program is part of the members’ pharmacy benefit, the members need to go to the CVS Pharmacy window. If members ask to use their pharmacy benefit at the CVS front checkout, staff will redirect members to the pharmacy window.
Members who choose to self-pay and seek reimbursement will need to submit reimbursement requests via the Caremark online portal. Members will need to sign in or register at Caremark.com and then follow the prompts to upload a copy of their receipt for submission. (Find instructions here.) CVS Caremark also supports a mobile app (available for Android and Apple devices) available through the app store.
When submitting reimbursement requests through the Caremark portal, a member attestation will be required. The attestation confirms that the at-home COVID-19 test is for personal use and not for resale.
Members may also submit paper claims to CVS Caremark for reimbursement. The paper claim will require the same member attestation that the test is for personal use and not for re-sale. Members will also need to provide a copy of the receipt as proof of purchase. Reimbursement checks will be mailed from CVS Caremark, not PacificSource Health Plans.
CVS Caremark mail order is not currently dispensing at-home COVID-19 tests. It is advised that members first check to see if the pharmacy is participating in the zero-cost at-home test program. Members may access other contracted online pharmacies such as Amazon Pharmacy, to obtain zero-cost at-home tests. To obtain a mail order at-home COVID tests or to access Amazon Pharmacy, members will need to provide their pharmacy information as noted above. Please note that shipping and delivery charges may apply. Prescriptions purchased through the regular Amazon store, including Amazon Prime, will be considered out of network and reimbursed as described below.
Each eligible member is able to receive up to 8 tests every 30 days.
No, the limitation of 8 at-home COVID-19 tests per 30 days is for both in- and out-of-network pharmacies and does not accumulate independently.
No, the limitation of 8 at-home COVID-19 tests per 30 days does not include tests administered at a provider’s office.
Medicaid and Medicare members
At-home COVID-19 tests are covered when obtained from a pharmacy enrolled with Oregon Medicaid (OHP). A member is allowed 4 at-home tests per month. If they require additional tests they must receive a prior authorization from their plan. At-home tests must be purchased through the pharmacy. At-home tests purchased by the member are not eligible for member reimbursement.
Oregon Medicaid members may request free tests under the federal government program by ordering online at CovidTests.gov or by calling 800-232-0233 (TTY 711) to get help in English, Spanish, and more than 150 other languages. This phone line is available from 5:00 a.m. to 9:00 p.m., Pacific time, 7 days a week.
Members with disabilities can get help placing their order through the Disability Information and Access Line, 888-677-1199, 6 a.m. to 5 p.m., Pacific time, Monday–Friday, or email DIAL@USAgingAndDisability.org.
At-home tests are not covered for Medicare members. Medicare members may go to a doctor’s office, clinic, urgent care, emergency room, or a retail pharmacy to be tested.
Medicare members may also request free tests under the federal government program by ordering online at CovidTests.gov or by calling 800-232-0233 (TTY 711) to get help in English, Spanish, and more than 150 other languages. This phone line is available from 5:00 a.m. to 9:00 p.m., Pacific time, 7 days a week.
Members with disabilities can get help placing their order through the Disability Information and Access Line, 888-677-1199, 6 a.m. to 5 p.m., Pacific time, Monday–Friday, or email DIAL@USAgingAndDisability.org.
Self-funded plan sponsors
Claims processed through the pharmacy benefit will have a quantity limit coded, which will only allow 8 at-home COVID-19 tests to pay every 30 days. Requests for more than 8 tests per 30 days will require a prescription supported by a clinical statement of need and a prior authorization. In addition, if a confidentiality agreement is in place, self-funded clients may request monthly reporting for oversight of pharmacy claims.
No, a plan amendment is not needed; the at-home COVID-19 tests are only covered through the duration of the National Public Health Emergency.