COVID-19 Treatment Coverage
Treatment and Outpatient Services
Effective Oct. 1, 2021, services for the treatment of COVID-19 – including outpatient services for post COVID-19 treatment – will be paid as normal plan benefits. Examples include occupational therapy, physical therapy and durable medical equipment.
Due to the pandemic, federal and state authorities may provide guidance related to extended member rights, such as appeal rights and enrollment rights. Here is an explanation of these updates.
COVID-19 antibody testing is available at Avera QuickLabs and other Avera clinic locations. At Avera, this test is provided at an out-of-pocket cost of $50 and is eligible for the Flexible Spending and Health Savings Account (HSA). If ordered by a provider for medically necessary reasons, the test will be covered by insurance at no cost to you.
At-Home COVID-19 Test Reimbursement
Many Avera Health Plans members are able to purchase over-the-counter (OTC) at-home COVID-19 tests, at little or no cost to you. To help you better understand the benefit, review the frequently asked questions (FAQs) below.
- Effective Jan. 15, 2022, the Federal Government announced that insurance companies and group health plans are required to cover the cost of over-the-counter (OTC) at-home COVID-19 tests. These tests are sold at retail stores and pharmacies as an over-the-counter test and do not require a doctor’s order.
- Reimbursement only applies to antigen rapid home tests purchased on or after Jan. 15, 2022. This mandate is in effect until the end of the federal public health emergency.
- To be eligible for reimbursement of an over-the-counter (OTC) at-home COVID-19 test, the test can only be used for personal use and cannot be used for required employment testing or for resale purposes. Reimbursement cannot be made if the test has been reimbursed by another source such as a Health Savings Account (HSA), Flexible Spending Account (FSA) or Health Reimbursement Account (HRA) or obtained as a free test.
Where can I go to purchase an OTC at-home COVID-19 test?
We’re partnering with CVS Caremark, our pharmacy benefit manager (PBM) and its vast nationwide pharmacy network to provide our members with a preferred network of OTC retailers to obtain approved at-home COVID-19 tests. Members may visit any in-network pharmacy and receive approved at-home COVID-19 tests without paying any upfront costs.
For a list of in-network pharmacies, log into your member portal at CVS Caremark.
Note: All pharmacies participating in the CVS Caremark network have the option of participating in offering the point-of-sale option to Avera Health Plans members. Pharmacies do have the option to opt out. Members may call ahead to their local pharmacy to determine participation. If a CVS Caremark in-network pharmacy elects to opt out, members can still purchase at-home COVID-19 tests and seek reimbursement.
What if my pharmacy can’t directly submit my claim for an OTC at-home COVID-19 test?
If your pharmacy is unable to directly submit the claim, you can do either of the following:
- Complete and submit a Pharmacy Claim Submission form. Completed forms and receipt(s) should be mailed to the address indicated on the form.
- You can submit a digital form at Caremark.com or via the CVS Caremark mobile app (available for Android and Apple)
Tests that are purchased at a location as described above will be reimbursed. You will not be reimbursed if you purchase a test from an individual, online auction or resale marketplace.
Who is eligible for reimbursement?
If you have private, employer-sponsored or student health commercial insurance, you're eligible to get reimbursed for OTC at-home COVID-19 kits.
This coverage reimbursement policy doesn't apply to members who have Medicare, Medicare Supplement, Medicaid or voluntary insurance.
What tests are covered?
- Tests must be approved, cleared or authorized by the US Food and Drug Administration (FDA). FDA approved at-home COVID-19 tests are found on the FDA’s listing for In Vitro Diagnostics EUAs - Antigen Diagnostic Tests for SARS-CoV-2.
- OTC at-home COVID-19 tests don’t require an order from your physician to qualify for reimbursement.
- Tests that are ordered by a provider are not subject to the reimbursement or quantity limit.
- Tests must be used to diagnose a potential COVID-19 infection. Tests used for employment, school or recreational purposes are not eligible for reimbursement.
What steps should I take to get an OTC at-home COVID-19 test at no cost?
The simplest way to receive an OTC at-home COVID-19 test at no cost is to visit an Avera Health Plans in-network pharmacy who is participating in direct coverage of OTC at-home COVID-19 tests.
Bring the test kit and your Avera Health Plans member ID card to the pharmacy counter (not the front register) when purchasing an FDA approved at-home COVID-19 test. Your pharmacy will process the test through your pharmacy benefit.
Can I be reimbursed by Avera Health Plans for an at-home COVID-19 test I've already purchased?
Yes. Members who have purchased an FDA-approved, at-home COVID-19 test on or after Jan. 15, 2022, can submit a Over-the-Counter (OTC) At-Home COVID-19 Test Reimbursement Form (pdf) for reimbursement. Be sure to include all requested information and an itemized receipt.
Are there limitations on the number of tests I can purchase?
Yes. Each member on the plan is allowed up to eight FDA-approved at-home COVID-19 tests per individual every 30 days. For example, a family of four covered under the same plan could be reimbursed for up to 32 tests per 30-day period. Each test is counted separately even if multiple tests are sold in a single kit. So, if you buy one kit that includes two tests, we’ll reimburse you for up to four kits.
Are there limits on how much I am reimbursed per test?
Yes. There is a maximum reimbursement of $12 per test. Many COVID-19 tests are sold as a two-pack kit ($12 for each test) and would be reimbursed at a maximum of $24 per kit. Reimbursement amount is for the cost of the test only and does not include sales tax or shipping costs. Applicable taxes and shipping are the member’s responsibility.
Can I purchase an OTC at-home COVID-19 test that costs more than $12?
Yes. If you get an FDA approved test at an in-store Avera Health Plans in-network pharmacy, you won’t need to pay anything out of pocket. At any other location, you may purchase an FDA-approved test, but you will only be reimbursed at a maximum of $12 per test.
What if I purchased other items with my OTC at-home COVID-19 tests and those items appear on my receipt?
Only the cost of OTC at-home COVID-19 tests (at a maximum of $12 per test) will be reimbursed.
Can I submit a photo of a receipt?
Yes, a digital photo is acceptable for reimbursement, or you can send us a copy of the receipt with the completed reimbursement Over-the-Counter (OTC) At-Home COVID-19 Test Reimbursement Form (pdf).
How long will I be able to get reimbursed for OTC at-home COVID-19 tests?
At this time, at-home COVID-19 tests are eligible for reimbursement until the end of the public health emergency.
Can I get an at-home COVID-19 test directly from Avera Health Plans?
No. Avera Health Plans is not directly distributing at-home COVID-19 tests to our members.