Over-the-Counter Test Reimbursement

Over-the-Counter (OTC) COVID-19 Test Reimbursement Changes

As previously announced, Highmark, together with its pharmacy benefit manager, Express Scripts, provided the following options for members with prescription drug coverage through Highmark to obtain FDA emergency use-authorized OTC COVID-19 tests with no upfront out of pocket expense. Additional details regarding the member-specific process can be found at

  1.  Members can purchase tests at preferred* network pharmacies
  2.  Members whose plans permit use of Express Scripts mail order pharmacy can order tests directly through Highmark’s pharmacy benefit manager, Express Scripts

Note: This benefit will cover up to eight (8) tests per member per month for a $0 copay.  

Additionally, members will have the ability to purchase FDA emergency use-authorized OTC COVID-19 tests outside of the preferred pharmacy network and can seek reimbursement via their member portal. Detailed instructions and information for members can be found on

Given the options outlined above, we are confident that the processes and procedures that we’ve established ensure compliance with the federal safe harbor guidance for groups who contract with Highmark for pharmacy benefit management services. Therefore, effective February 14, 2022, the reimbursement amount for member submitted claims for such groups will be at the lesser of cost or $12 per test as permitted under the safe harbor guidance. This change only applies to the member submitted claims alternative and not the direct coverage options listed above. 

For fully insured clients whose Highmark insurance policies do not include pharmacy benefit coverage or a pharmacy mail-order pharmacy benefit option: 

Highmark will implement an OTC COVID-19 test mail-order option for their members through Express Scripts Pharmacy. This will ensure that their members have access to the required direct to consumer shipping program where tests can be directly obtained with no upfront cost. 

For ASO clients that do not contract with Highmark for pharmacy benefit management services: 

We recommend working with your current pharmacy benefit manager (PBM) to develop a safe harbor compliant process that allows for no upfront out-of-pocket costs for your members. Please note that Highmark will continue to reimburse member submitted claims at cost until it receives written confirmation of these arrangements from ASO clients. If your PBM cannot or has not set up a process, please contact your Highmark representative to discuss options.

*The preferred pharmacy network will be the same as the member’s current pharmacy network for prescriptions. If members are unsure which pharmacies are in network, members can visit their website or call the number on the back of their Highmark insurance card for help. 

Mandate Does Not Cover Workplace-Required Testing:

OTC testing used for employment purposes is not covered under this mandate. 

Waste, Fraud, and Abuse Controls:

Highmark is committed to investigating and mitigating instances of health insurance fraud. By using our proven multi-pronged approach of pre-pay edits and post-pay analytics, we will work diligently to identify and address areas of risk for fraudulent activity.

  • We will use advanced analytics to help identify suspect activity and we will investigate accordingly. The primary edits that we need are to limit the quantity of tests to eight per member per month and cap reimbursement to $12 per test (if we or a carve-out PBM client has a preferred pharmacy network and direct retailer in place). 
  • We’ll also monitor the proof of purchase that comes in from members (e.g., paper receipts) to help ensure they appear to be valid. Analytics will help us to monitor for members who max out the test limits on a recurring basis and we’ll investigate accordingly. 
  • We will also look for price gouging, although there may limited options to address this if we do not have a preferred network and direct retailer in place.

Thank you for your continued partnership as we work to keep all our members healthy and safe during this pandemic.

If you have any questions, please contact your Highmark representative.