Since the start of the pandemic, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) has fully covered COVID-19 tests ordered by a health care provider that have been FDA-approved or received emergency use authorization (EUA).
Now, we’re making tests more accessible and lowering member costs by covering eight (8) approved over-the-counter (OTC) tests per member each month, beginning January 15, 2022, and continuing throughout the current public health emergency (PHE).
These tests do not have to be ordered by a doctor and can be self-administered and self-read at home.
Purchasing an OTC Test
Members have several options for purchasing an OTC COVID-19 test.
Members on an Employer's Group Plan and Individual Members:
1) Purchase at a local pharmacy counter using a Blue Cross NC prescription benefits card to pay no out-of-pocket costs
Members who plan to get their eligible OTC COVID-19 test from an in-network pharmacy must present their prescription benefits card, the same way they purchase their prescriptions. By purchasing at an in-network pharmacy counter, insurance is filed electronically, allowing members to purchase the test with no out-of-pocket costs. Purchasing OTC COVID-19 test kits is not limited to a particular pharmacy chain and includes, Walmart, Walgreens, Kmart, CVS, EPIC Pharmacies, various Independent Pharmacies and more:
2) Purchase at an out-of-network pharmacy or any location other than a pharmacy counter, pay out-of-pocket for the tests and submit a claim form to be reimbursed up to $12 per test
If a local pharmacy is not able to directly cover the cost of tests, members can pay out-of-pocket and mail an eligible OTC COVID-19 test claim form to Prime Therapeutics (our pharmacy benefit manager), for reimbursement. This applies to members who purchase OTC tests without their Blue Cross NC prescription drug card at an out-of-network pharmacy or location other than a pharmacy counter.
- Beginning April 4, 2022, and until the public health emergency (PHE) ends, participating pharmacies and health care providers will bill Medicare for OTC tests and there will be no out-of-pocket costs for members on Medicare plans.*
- Medicare members (including members with a Medicare Supplemental or Medicare Advantage plan) should check with their pharmacy or health care provider to determine if they are participating in the initiative to provide free OTC COVID-19 tests.
- These tests are available to anyone with Medicare Part B coverage, including those with a Medicare Advantage plan. Medicare members are not eligible for reimbursement from Blue Cross NC for these tests.*
For Members on an Employer's Group Plan and Individual Members:
- Reimbursement for test kits purchased from out-of-network pharmacies and retailers is limited to no more than $12 per individual test. To be reimbursed, the test must be FDA-approved or have emergency use authorization.
- Eligible members will receive up to eight (8) OTC COVID-19 tests per month for reimbursement. Each test is counted separately regardless of how many tests are sold in one package.
When submitting a claim to be reimbursed, members must mail a:
- Completed OTC COVID-19 test claim form*
- Purchase receipt documenting the date of purchase and the price of the test
- The test’s UPC code
The address to mail the OTC COVID-19 test claim form is:
Mail route: Commercial
PO Box 25136
Lehigh Valley, PA 18002-5136
Upon receipt of the required materials, Prime will issue a reimbursement check, typically within 21 days. Depending on volume, additional time may be needed for processing.
Most Blue Cross NC members should not need reimbursement for their OTC COVID-19 tests. If members present their Blue Cross NC member ID card at an in-network pharmacy counter, they will pay no out-of-pocket costs.
Medicare members must receive their OTC tests from a participating pharmacy or health care provider and are not eligible for reimbursement from Blue Cross NC. See coverage guidelines, participating pharmacies and health care providers on Medicare.gov.
*Note: the claim form should be completed for OTC COVID-19 tests. A pharmacist signature and pharmacist NPI number are NOT required on the claim form. However, the member MUST sign the form attesting that the test kits are not being used for testing required by their employer, return to work, travel, attending recreational events, and will not be resold.
- OTC testing coverage applies to members of Blue Cross NC's fully-insured (individual and group), Administrative Services Only (ASO) group health plans and the Federal Employee Plan (FEP).
- The requirements do not apply to excepted benefits (such as stand-alone vision or dental) or retiree-only plans.
- If the back of your Blue Cross NC ID card doesn't list Prime as your prescription drug plan, you may have a different pharmacy benefit manager. If this is the case, please ask your employer or benefits manager about your OTC testing reimbursement options.
- COVID-19 tests for general workplace health and safety (such as employee "return to work" programs) are not required to be covered.
- For Medicare members, Medicare will cover up to eight over-the-counter COVID-19 tests per calendar month when picked up at a participating pharmacy or health care provers. See coverage guidelines, participating pharmacies and health care providers on Medicare.gov.
- North Carolina Department of Health and Human Services (NCDHHS) Testing Information
- Testing Options in North Carolina
- Testing Locations Beyond North Carolina
- Order Your Free At-Home COVID-19 Tests from the Federal Government
- List of North Carolina In-Network Pharmacies for OTC Tests
- At-Home Testing Guidance for the General Public (Spanish)