COVERAGE GUIDELINES FOR AT-HOME TESTS
- Eligible EHIM members will need to obtain the at-home tests at one of our participating pharmacies and present their medical/EHIM ID card at time of purchase. No prescription is required.
- The participating pharmacy will submit the at-home tests electronically just like a regular prescription along with the patient information.
- EHIM’s system is set up to verify eligibility, monthly quantity limitations and other plan design edits.
- If all dispensing criteria are met through real-time electronic adjudication, the claim will process a $0 copay to the member.
- A maximum reimbursement of $12 per test ($24 for a box of two) will apply, along with any applicable dispensing and administration fees.
- Coverage is limited to a maximum of eight tests per person per 30 days.
If a member purchases an at-home test and pays out-of-pocket, they can submit the expense as a paper claim to EHIM and we will process it just as we process other manual pharmacy claims. All edits, including eligibility and quantity limitations, would apply to the paper claim and member would be reimbursed a maximum of $12 per test ($24 for a box of two).
While we are unable to control the available inventory at any of our participating pharmacies, our systems support the online processing of these tests when members utilize any of our participating pharmacies and present their ID card.
EHIM members can call our 24/7/365 Pharmacy Help Desk with any questions related to at-home COVID-19 tests at 800-311-3446.
Need to submit a reimbursement? Download the At-Home COVID Test Kit Reimbursement Form.
FREQUENTLY ASKED QUESTION
Are at-home tests covered under the medical benefit or the prescription drug benefit?
FDA approved at-home COVID-19 tests should only be covered under the EHIM pharmacy benefit. This will ensure that the cap of eight tests per person per 30 days can be tracked.
Will the plan provide a direct coverage program, or will participants be required to purchase the tests and then seek reimbursement?
EHIM is providing a direct coverage program. Controls have been put in place to verify eligibility, quantity limits per person and process transactions in real-time. If all dispensing criteria is met and claim is processed electronically, member will receive the at-home test for $0 out-of-pocket. There may be instances when a pharmacy may require you to pay out-of-pocket and submit for reimbursement. In these cases, EHIM’s reimbursement form can be found at: AtHomeCovidReimbursementForm.pdf
When will EHIM’s direct coverage program be available?
Our pharmacy claims system can support a direct coverage program for at-home tests effective January 15, 2022.
How will plans monitor purchases to ensure that the tests are only purchased for the participant (including covered family members)? What documentation will the plan require?
EHIM’s system is set up to verify member eligibility, manage monthly quantity limitations and all other applicable dispensing edits for at-home tests just as eligibility is verified for other prescriptions when the prescription is submitted electronically.
How will the number of tests that have been filled be monitored?
EHIM’s pharmacy claim system supports the quantity limitations of eight tests per member per 30 days. If members try to fill more than eight tests per member per month, the claim will reject at the time of fill. For this to be monitored correctly, at-home COVID-19 test claims must be processed through the EHIM pharmacy benefit only.
What is the reimbursement process if a member pays out-of-pocket for at-home tests? How will EHIM reimburse these expenses?
If a member purchases a test at an out-of-network pharmacy and pays out-of-pocket, they may submit the receipt along with a prescription reimbursement request just as they would other pharmacy claims. EHIM will process the request as a manual pharmacy reimbursement and all standard edits including eligibility, quantity limitations, and other utilization edits would apply in order to be considered for reimbursement. Members will be reimbursed a maximum of $12 per test ($24 for a box of two). EHIM’s reimbursement form can be found at: AtHomeCovidReimbursementForm.pdf. Tests purchased from private individuals, online auctions, or resale marketplaces are not eligible for reimbursement. Tests must be purchased from established retailers.
What if a member pays more than $12 for a test?
If a member purchases a test and pays out-of-pocket, he/she will be reimbursed a maximum of $12 per test ($24 for a box of two). Taxes and/or shipping charges are not included in reimbursement. To purchase tests with a $0 copay, we encourage members to use a participating pharmacy to have the claim processed electronically.
Will there be a sufficient number of tests to meet the demand?
EHIM does not control the available inventory at our participating pharmacies. While we understand there is currently limited inventory, expectation is that availability of tests will increase over time.
How long will it take for EHIM to process manual reimbursements?
A member should expect the claim to be processed within 30 days from the time EHIM receives the request. If there is any required information missing or the reimbursement request is not filled out completely, this may cause a delay in processing until EHIM receives all required information.
I bought some at-home testing kits prior to January 15, 2022. Can I be reimbursed?
In accordance with federal guidelines, EHIM will cover the cost of approved testing kits (as noted above) beginning Jan. 15, 2022. Kits purchase prior to that date are not eligible for reimbursement.