OTC – COVID-19 DIAGNOSTIC TESTS

  • Key highlights:

    • Starting Jan. 15, 2022, coverage for at-home COVID-19 diagnostic OTC tests is required for all Blue Cross and Blue Shield of Texas (BCBSTX) fully insured and self-insured groups, and individual and family plans.
    • Requires group health plans and issuers to cover FDA-authorized COVID-19 diagnostic OTC tests without a prescription or health assessment from a provider
    • Coverage must be provided:
      • Without cost-share, up to $12 per test under the safe harbor (for plans that provide access to the tests through a pharmacy network and direct-to-consumer shipping program, with no up-front cost to the member)
      • Without prior authorization or medical management techniques
      • OTC tests purchased prior to Jan. 15, 2022, are not in scope
    • Allows coverage of eight (8) tests per covered member, every 30 days (or, for example, 4 boxes with 2 tests per box)
    • Coverage is effective through the end of the federal public health emergency
    • At-home testing for employment purposes is not considered a covered benefit under this federal guidance
  • What this means to you: 

    BCBSTX will cover COVID-19 diagnostic OTC tests through our extensive network of participating pharmacies, who have Prime Therapeutics® coverage through BCBSTX.

    Members can use the same broad networks used for COVID-19 vaccines to request tests. Claims will be submitted directly from the pharmacy to BCBSTX.


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  • In-network pharmacy locations include:

    • Point-of-sale at more than 65,000 in-network pharmacies
    • Member-submitted claims processing directly through Prime’s current process using the Prescription Drug Claim Form.
    • Direct-to-consumer shipping (allows members' ability to order COVID-19 tests directly through a vendor partner, such as Walgreens and other major pharmacy chains. We may have more vendors join in the future.)

Information and Flyers

  • Self-insured customer:

    For our self-insured customers who use BCBSTX and Prime Therapeutics to administer their pharmacy benefit, here's our approach:

    • Covered under pharmacy benefits, not medical
    • Point-of-sale at more than 65,000 in-network pharmacies
    • Direct-to-consumer shipping

Claim Forms