COVID-19 At-home Testing Coverage Questions

Members of fully-insured commercial plans, fully-insured group Medicare Supplement plans, and self-insured commercial plans that do not carve out pharmacy, will have the option of purchasing tests and submitting a claim for reimbursement to Tufts Health Plan, or obtaining a test through their pharmacy benefit without upfront cost at certain Caremark-affiliated pharmacies. Visit COVID-19 Testing & Coverage for more information.

For tests obtained at the pharmacy, members should present their ID card at the pharmacy counter.

Note: Self-insured employer groups who carve out pharmacy coverage to a third party may choose to administer this benefit exclusively through their pharmacy benefit manager (PBM). Members of self-insured groups should follow up with their employer to confirm their coverage options.

Yes. Self-insured groups who have chosen to carve out pharmacy to a third party may have their PBM administer the at-home test benefit. Members of self-insured groups should follow up with their employer to confirm their coverage options.

Coverage is available through our pharmacy network without upfront costs to members. We are evaluating the possibility of establishing a more comprehensive direct coverage program.

We will make our best efforts to process member reimbursements within 30 days of receipt – assuming their reimbursement forms and receipts are complete.

Updates will be made to the COVID-19 Resource Center on our public website.

We are in the process of determining how to create a bi-directional feed to ensure the allowed number of tests per month is not exceeded regardless of how the tests were covered (via the pharmacy or through the member reimbursement process).

COVID-19 test-reporting capabilities are being assessed at this time.

1. If so, have you started any discussions with pharmacies, stores, and retailers to be able to create the preferred network?
2. Can you provide an overview of how this process will work and how this setup will be structured from an administrative perspective?

Coverage is available through certain pharmacies in our pharmacy network without upfront costs to members. We are evaluating the possibility of establishing a more comprehensive direct coverage program. Please visit COVID-19 Testing & Coverage for more information.

Yes. These claims will be processed for member reimbursement through the medical benefit. Tests purchased through resellers (e.g., eBay, Facebook Marketplace, etc.) are not eligible for reimbursement.

Members who purchase and pay out-of-pocket for at-home tests will be asked to follow the member reimbursement process detailed in the COVID-19 At-home Test Member Reimbursement Form. We will make best efforts to process reimbursements within 30 days of receipt.

The limit will be based on calendar month.

Note: In the event a member obtains less than eight tests in a given calendar month, they do not roll over into the next month (e.g., if a member receives six tests in January, they are not able to receive 10 tests in February).

No. At this time there is not a $12 cap on tests obtained outside of the preferred network.

No. Members will be reimbursed for tests purchased on or after January 15, 2022.

Please visit COVID-19 At-home Testing for a list of tests that are eligible for coverage.

No. ASO accounts are subject to the FFCRA and CARES Act requirements.

We are not assessing a fee for processing the member reimbursements. We will reimburse members the cost of the tests minus tax and shipping.

If we develop a direct coverage method that meets the federal statutory criteria that includes both a pharmacy network and a direct-to-consumer shipping program, reimbursement may be capped at $12 per test for tests obtained outside of the preferred network.

No, tests purchased through a reseller (i.e., the employer group) are not eligible for reimbursement.