On January 10, 2022, the Biden Administration announced that, beginning January 15, individuals with private health insurance coverage or covered by a group health plan who purchase an over-the-counter COVID test authorized, cleared, or approved by the U.S. Food and Drug Administration (FDA) will be able to have the test costs covered by their plan or insurance. Insurance companies and health plans are required to cover up to eight over-the-counter at-home tests per covered individual per month.
We understand that finding available test kits may be challenging during this time. The Biden administration has also purchased 500 million over-the-counter at-home tests to be distributed for free. Currently, every home in the U.S. is eligible to order 4 free at-home COVID-19 tests. The tests are completely free, and orders will usually ship in 7-12 days. Please visit https://www.covidtests.gov/ for further information and to order a test.
Over-the-counter test purchases will be covered without the need for a health care provider’s order or individualized clinical assessment, and without cost sharing requirements such as deductibles, copayments, or coinsurance, and may not require prior authorization.
The cost of tests purchased from network pharmacies will be covered up front or you may pay out of pocket and apply for reimbursement. For tests purchased from an out-of-network pharmacy or retailer, the participant may apply for reimbursement. However, if the employer chooses not to leverage its relationship with network pharmacies to make tests available to plan participants, the plan will be required to reimburse the full retail cost of the tests. If the plan’s pharmacy network is available for purchasing the test (i.e., the plan makes the test available with no upfront cost to the participant), plans are not required to reimburse more than $12 per individual test purchased from an out-of-network pharmacy or retailer.
We are committed to keeping you informed on the latest developments. We’ve provided some frequently asked questions (FAQs) regarding the COVID-19 At-Home Test Kits to guide you through the process, including the COVID-19 testing kit reimbursement forms. You can review them below.
AT-HOME COVID-19 TEST KIT REIMBURSEMENT FORM – English
AT-HOME COVID-19 TEST KIT REIMBURSEMENT FORM – Spanish
ORDER FREE AT-HOME COVID-19 TESTS THROUGH USPS
Residential households in the U.S. can order one set of 4 free at-home tests from USPS.com. Here’s what you need to know about your order:
COVID-19 AT-HOME TEST KITS – FAQs
Which at-home tests are covered?
Any FDA-authorized or approved tests purchased on or after January 15, 2022 are the tests that are covered. Typically, FDA-authorization is shown on the test packaging.
Which benefit provides coverage?
PinnacleRx Solutions Members
Coverage will be provided by our pharmacy benefit management (PBM) company if the plan has coverage through PinnacleRx Solutions.
Non-PinnacleRx Solutions Members
If the plan/member has its pharmacy benefit carved out to another PBM, we encourage reaching out to that PBM. However, we can provide reimbursement for non-PinnacleRx Plans upon written request from the Plan.
Is there an out-of-pocket cost?
Test kits purchased by PinnacleRx Members at in-network pharmacies will adjudicate at point-of-sale with $0 copay.
The $0 co-pay is subject to a maximum of 8 tests per member per month until further notice.
All Other Retailers:
Test kits purchased at out-of-network pharmacies or retailers are eligible for a maximum member reimbursement of $12/test.
Please note, however, that if the plan does not provide direct coverage through its pharmacy benefit manager (i.e., does not leverage its relationship with its pharmacy network), the plan will be required to reimburse the full cost of tests purchased, regardless of whether they were purchased from an in-network or out-of-network source.
If I incur an out-of-pocket cost, am I eligible for reimbursement?
Yes –The member must complete and submit COVID-19 Test Kit Reimbursement Form with accurate information in addition to an itemized receipt. A separate claim form for each family member is required and itemized receipts must reflect the patient’s name.
Tests purchased from network pharmacies/retailers will be reimbursed at the negotiated rate. Reimbursement for tests purchased from an out-of-network pharmacy/retailer will be limited to $12 per eligible test, unless the plan is not providing coverage for COVID-19 tests through its network of participating pharmacies.
Can you explain the reimbursement process?
At this time, reimbursement requests for claims incurring out-of-pocket costs can be submitted by completing a COVID-19 Test Kit Reimbursement Form with an itemized receipt.
We are working on developing an electronic claim reimbursement form and we will update this document when it is complete.
Is there a quantity limit on test kits?
Yes – Currently, each member is eligible to receive a maximum of 8 at-home test kits with a $0 co-pay each month.
How do I know if a pharmacy is in-network?
Please reference the Pharmacy Locator Page on the PinnacleRx Solutions’ website to locate in-network pharmacies.
What types of tests are not covered?
- Non-FDA authorized OTC tests
- Non-OTC tests (e.g. PCR tests, Laboratory Tests, and Physician Ordered/Administered tests are not part of this program)
- Work related testing. Health plans are not required to provide coverage of testing (including an at-home over-the-counter COVID-19 test) that is for employment purposes.
Where can I obtain a test?
You may obtain test kit at your local in-network pharmacy. Please use the Pharmacy Locator Tool to inquire with pharmacies in your area about availability.
PinnacleRx Solutions is working with its in-network pharmacies and supply chain partners to develop a mail-order program for test kits.
We understand that finding available test kits may be challenging during this time. The Biden administration has also purchased at-home tests to be distributed for free. Currently, every home in the U.S. is eligible to order 4 free at-home COVID-19 tests.
The tests are completely free, and orders will usually ship in 7-12 days. Please visit https://www.covidtests.gov/ for further information and to order a test.
We will update when we have more information on this program. For updates and FAQs in Spanish, please click here.