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Update: BCBSNM Approach to OTC COVID-19 Testing Coverage

January 14, 2022

Applies to Group and Retail 

As you’re aware, the federal government released guidance this week about coverage of over-the-counter (OTC) COVID-19 diagnostic tests. 

Some 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 New Mexico (BCBSNM) fully insured and self-insured groups, and individual and family plans 
  • Requires group health plans and issuers to cover 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: BCBSNM will cover COVID-19 diagnostic OTC tests through our extensive network of participating pharmacies, for our fully insured members, and self-insured group members who have Prime Therapeutics® coverage through BCBSNM. 

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

In-network locations include:

  • Point-of-sale at more than 65,000 in-network pharmacies
  • Member-submitted claims processing directly through Prime’s current process
  • Direct-to-consumer shipping (allows member 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.)

Self-insured customer approach:

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

  • Covered under pharmacy benefit, not medical
  • Point-of-sale at more than 65,000 in-network pharmacies
  • Direct-to-consumer shipping
  • There is no option to opt-in or opt-out of diagnostic testing coverage

Our self-insured customers who have their pharmacy benefits carved-out will need to confirm how their carved-out PBM is managing COVID-19 diagnostic OTC testing.

While we provide information about federal guidance, we do not provide groups with legal or compliance advice. Group customers must contact their legal advisors if they have questions about proposed rules and new regulations, what they will require and how they will affect their benefit plans if finalized.

This information applies to members and groups with prescription drug benefits administered through Blue Cross and Blue Shield of New Mexico (BCBSNM).

BCBSNM contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. In addition, contracting pharmacies are contracted through Prime Therapeutics. The relationship between BCBSNM and contracting pharmacies is that of independent contractors. BCBSNM, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.