COVID-19 Diagnostic Testing Kits FAQ
EBPA During the Pandemic
EBPA was well positioned when this pandemic started as most of our support and operations functions were already set up to accommodate a “virtual world.” We are proud that we have maintained disruption-free service to our plans and members during this time.
As drugs, vaccines, and tests are being approved or authorized for COVID-19, EBPA is committed to providing information that is credible and easy to understand. We have launched a COVID-19 Resource Center with helpful reference material related to the pandemic, and steps everyone can take to stay safe and informed.
On January 10, 2022, the Departments of Health and Human Services (HHS), Labor, and the Treasury (collectively termed, “The Departments”) released published guidance regarding the requirement that commercial market plans and insurers cover over the counter (OTC) COVID-19 tests without cost sharing during the COVID-19 public health emergency (PHE) without a health care provider’s involvement or prescription.
They also released Frequently Asked Questions (FAQs) regarding the implementation of the Families First Coronavirus Response Act (FFCRA), the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), and the Affordable Care Act (ACA) on January 10, 2022, regarding COVID-19 diagnostic testing. This follows President Biden’s December 2 announcement.
EBPA is actively monitoring the COVID-19 landscape. Below you will find helpful information and answers to some of the most frequently asked questions about COVID-19 diagnostic testing kits and how it applies for our clients.
Plan & Member FAQ
Will EBPA cover over the counter (OTC) COVID-19 diagnostic tests coverage?
EBPA plans to process pharmacy claims for FDA authorized, cleared, or approved OTC COVID-19 antigen tests at $0 for members who utilize an in-network pharmacy. Members should check-out at the pharmacy counter with their pharmacy benefit (prescription)card. Members do not need a provider order or individualized clinical assessment to obtain these tests. Direct coverage at point-of-sale (POS)may only be provided for OTC COVID-19 tests with an associated National Drug Codes (NDC). Testing for employment purposes will not be covered.
3 Examples of FDA authorized, cleared, or approved OTC COVID-19 Antigen tests include, but are not limited to:
- INAXNOW COVID-19 AG SELF TEST
- CARESTART COVID19 AG HOME TEST
- ELLUME COVID-19 HOME TEST
- FLOWFLEX COVID-19 AG HOME TEST
- IHEALTH COVID-19AG RAPID TEST
- QUICKVUE AT-HOME COVID-19 TEST
Where can members purchase OTC COVID-19 tests?
Members can purchase OTC COVID-19 Tests at pharmacies using their pharmacy benefit.
When can members get OTC COVID-19 diagnostic tests at $0 co-pay?
Effective January 15, 2022, and for the duration of the public health emergency (PHE), EBPA plans to provide coverage of OTC, at-home, diagnostic COVID-19 antigen tests that have been authorized, cleared, or approved by the FDA. No retrospective reimbursement will be provided to members if tests are purchased prior to January 15, 2022.
How many OTC COVID-19 diagnostic tests will be covered for members?
During the PHE, EBPA will be providing coverage of 8 tests per 30-day period per member without cost-sharing requirements (including deductibles, copayments, and coinsurance), prior authorization, or other medical management requirements on such OTC COVID-19 antigen tests. This quantity limit aligns with federal guidance and our business strategies to expedite the direct coverage of OTC COVID-19 tests. The Federal Departments recognize that some OTC COVID-19 tests are sold in packages containing more than one test. In applying the quantity limit of 8 tests per 30-days, the Department allows plans to count each test separately, even if multiple tests are sold in one package. This quantity limit is set in place to discourage behaviors that could lead to future shortages.
Can members get more than 8 tests per 30-day period?
Members can get more than 8 tests per 30 days if the tests are ordered or administered by a health care provider following an individualized clinical assessment. This includes patients who may need more due to an underlying medical condition. Providers or pharmacies will need to outreach to the appropriate Pharmacy Benefit Manager (PBM) for overrides in these special situations. Please use the phone number listed on the back of the member ID card.
If no OTC COVID-19 tests are available, where can members get tested?
Testing is crucial to combating this pandemic. EBPA encourages members to seek COVID-19 tests at one of the many new federal testing sites around the country if OTC COVID-19 tests are inaccessible. The government has also purchased 500 million at-home rapid tests to be distributed to members for free of charge. The government will be launching a website with more information on how to order a free COVID-19 test.
How can members submit a Direct Member Reimbursement (DMR) claim?
Members who have purchased OTC Antigen COVID-19 tests from an out-of-network pharmacy may submit their claims for reimbursement if the product was FDA authorized, cleared, or approved and has a valid NDC. The maximum reimbursement possible per test is no less than the actual price or up to $12/test, whichever is lower. To submit a request for reimbursement, please call your Pharmacy Benefit Manager (PBM) and speak with a representative. If you are unsure who your Pharmacy Benefit Manager is, this information, along with a contact number, can be found on the back of your member ID card.
Can members use their FSA/HSA card to purchase these COVID-19 tests?
If members are planning to seek reimbursement via DMR from their prescription benefit, then they cannot use their FSA/HSA card to purchase these tests.
What are the different types of COVID-19 tests available?
There are two main diagnostic tests available to detect infection with SARS-CoV-2; the rapid Antigen test and the polymerase chain reaction (PCR)test.
- A PCR test is performed to detect the presence of a virus if you are infected at the time of the test. It could also detect fragments of the virus even after you are no longer infected. PCR tests are generally performed by a health care provider, require the submission of a sample to a lab, and can take a few days to process. Results may be received within 1-3 days of testing.
- A rapid antigen test can detect the presence of a virus similar to a PCR test. They are less expensive, can be purchased at a variety of pharmacies, and produce results within 10-15 minutes of testing. Antigen tests can be used in screening programs to quickly identify those who are likely to be contagious. However, they are less sensitive than most PCR tests and may be necessary to confirm antigen test results with a PCR test.
What educational resources are out there for members regarding OTC COVID-19 tests?
EBPA has created a COVID-19 Resource Center page with helpful reference material related to the pandemic, and steps everyone can take to stay safe and informed.
For more information regarding OTC COVID-19 tests, please visit reputable sources such as:
If you have any questions, please call, and speak with a representative at 800.258.7298 Monday – Friday 8AM to 6PM EDT. Or use our Contact Us page and a member of our
service team will reach back out to you.