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PEIA coverage for COVID-19 at-home testing

PEIA coverage for COVID-19 at-home testing

January 27, 2022

Update on COVID at-home Testing Program from PEIA

This information applies to members of the PEIA PPB Plan ONLY.  Members of the Health Plan and Humana should contact their plan for details of coverage and process. Note: for the most recent updates from PEIA regarding COVID-19, visit PEIA's COVID-19 page.

Apparently, the first email we sent out regarding at- home COVID-19 testing really sparked demand for at-home testing among public employees, which is a positive thing.  The downside is that this demand for testing has revealed problems with the program and the supply chain.  

Although we initially believed that all network pharmacies would be participating in the program to provide Point of Service (POS) claims processing for these tests, that is not the case.  What we have discovered is that it is up to individual pharmacies to determine how to handle these at-home test claims. 

Many pharmacies were already facing staffing shortages and additional work in providing vaccinations, and many have simply determined that they cannot take on this extra responsibility for processing claims for over-the-counter tests. Had we known, we NEVER would have sent out the instructions we did, as soon as we did.  

This is a developing program, since it's only been two weeks since it was announced, and providers and plans are still adjusting to it.  We hope, eventually, to have the program work the way we initially announced, but for now, if the pharmacy refuses to process the POS claim for COVID test(s), the member will have to pay and submit the claim to CVS/Caremark.  Members will be reimbursed up to $12 per test, and so should be aware of the price they are paying for tests.

Members can submit claims by one of two methods:

  • Preferred digital method: Members login to Caremark.com and can upload a copy of their purchase receipt for the OTC COVID test. There are instructions for the member upon log in to the site. This method is currently in use, and CVS/Caremark is observing a seamless experience for online receipt submission of member-purchased OTC COVID tests.  Below is a specific link for OTC COVID-19 test reimbursement that provides more information for members, including a frequently asked questions section at the bottom.

OTC COVID-19 Tests Reimbursement FAQs

  • Paper claim: An abbreviated paper claim form is being created specifically for OTC COVID test reimbursement, and CVS/Caremark will provide when available.

We regret any confusion and additional frustration we've created.  It was not our intent. We appreciate your patience as we all navigate this changing world.

For more information, visit PEIA’s website at peia.wv.gov

Your PEIA Team


January 20, 2022

In accordance with the latest federal mandate, PEIA will cover at-home, self-administered COVID-19 test kits for PEIA PPB Plan members without a prescription, effective January 15, 2022. The easiest way to get your kits, at no cost to you, is to pick them up at a participating pharmacy and ask the pharmacy to bill PEIA. CVS/Caremark has set up their system to process these claims and not charge you a copayment as long as the pharmacist submits the claim as they would any other prescription claim.

Coverage is limited to eight over-the-counter COVID-19 at-home tests per covered individual in the household per 30-days without a healthcare provider order or clinical assessment. If multiple tests are sold in one package, i.e., if one package includes two tests, it counts as two tests toward the quantity limit.

Tests that can be purchased at a retail location or online but are then sent to a lab for processing are covered under your medical benefit and should be submitted to UMR. They are not covered unless accompanied by a doctor's order.

To be eligible for reimbursement, the purchased COVID-19 tests:

  • must be purchased on or after January 15, 2022
  • must be for personal diagnostic use
    • used to identify the potential COVID-19 infection
    • not be used for employment purposes
    • not used for surveillance testing
  • will be self-administered with results that can be self-read
  • will not be resold, given or supplied to persons other than family members covered under the same policy
  • will not be reimbursed by another source

If you already paid for at-home, self-administered COVID-19 test kits after January 15, you can submit a claim for reimbursement to CVS/Caremark following the instructions in your Summary Plan Description.

Read the full PEIA article.