Coverage for at-home
COVID-19 tests
Updated on April 10, 2024
The end of the public health emergency (PHE)
On May 11, 2023, the federal public health emergency came to an end. As a result, a number of policies put into place at the beginning of the PHE will also be ending. For more information, visit cdc.gov/coronavirus/2019-ncov/your-health/end-of-phe.
Fallon Health is covering over-the-counter COVID-19 tests for all Fallon members whose plan includes a pharmacy benefit. Please note that Fallon Health also covers medically necessary PCR and antigen tests at no cost.
For Community Care members with pharmacy benefits
For Community Care members, we will cover 8 tests per member per month through December 31, 2023. Beginning January 1, 2024, we will cover 2 tests per member per month.
Where to get test kits
You can get FDA-authorized COVID-19 test kits at Kinney Drugs, Sam's Club, Walgreens, Walmart and RiteAid at no cost to you. You will not need to submit a reimbursement form. Just go to the pharmacy counter, present your Fallon Health ID card and ask to have the product submitted to OptumRx. Coverage includes at-home COVID-19 test kits authorized by the Food and Drug Administration (FDA).The most common tests are BinaxNOW™, CLINITEST®, Flowflex™, i-Health®, InteliSwab™, On/Go™, QuickVue® and At-home test kits (Roche).
If you do not use one of the pharmacies listed above, keep your receipts and the name of your at-home test kit(s). You’ll need that information to submit a request for reimbursement.
How to get reimbursed for test kits
If you purchase an FDA-authorized over-the-counter COVID-19 test kit at other stores or online retailers, or if you paid out-of-pocket for a test kit on or after January 15, 2022, you can submit a request for reimbursement. You will be reimbursed for up to 8 tests per covered member, per month at up to $12 per test.
Please submit your claim within one year of your purchase date. Reimbursement will be available through the end of the emergency health period.
Or, order a test kit online through Optum at no cost
If you order test kits online through the Optum store, you will not have to pay any upfront cost. You will also get free shipping on orders that would equal $45 or more. You will need to go to optumrx.com and sign in to your account. You may need to create a new account if you do not already have one. Then, go to “Get at home COVID-19 tests with $0 copay,” then click on the “order now” link.
You can also access tests directly from the federal government by visiting covidtests.gov. Every home in the U.S. can order 4 free at-home COVID-19 tests. The tests will be completely free—there are no shipping costs, and you don’t need to enter a credit card number.
For members of NaviCare, Berkshire Fallon Health Collaborative, Fallon 365 Care, Fallon Health-Atrius Health Care Collaborative, and Summit ElderCare
We will cover the cost of up to eight over-the-counter FDA emergency use authorized tests per member per month without prior authorization through June 30, 2023. Effective July 1, 2023, two tests per member per month will be authorized without prior authorization.
You are covered for FDA-authorized at-home antigen COVID-19 test kits at no cost, up to $12 per test. Please note that some test kits include more than one test. For example, a BinaxNOW box includes two tests. You would be reimbursed $24 for that box.
How to get reimbursed for test kits
You cannot get reimbursed for tests that you have paid for out-of-pocket. The only way that you can access covered tests at no cost to you is by getting one of the approved tests (see below) at any network pharmacy. You will need to go to the pharmacy counter, show your Fallon Health ID card and ask to have the product submitted to OptumRx.
Coverage for the test kits will remain in place until September 30, 2024.
Where to get test kits
You can get one of the FDA-authorized COVID-19 test kits below at any network pharmacy at no cost to you. Just go to the pharmacy counter, show your member ID card, and ask to have the product submitted to OptumRx.
- BinaxNOW™
- Flowflex™
- i-Health®
- InteliSwab™
- QuickVue® At-home
Medicare is also covering test kits
Coverage through Medicare ended when the COVID-19 public health emergency (PHE) ended on May 11, 2023.
For Fallon Medicare Plus members with pharmacy benefits
Fallon Health will cover the cost of up to four over-the-counter FDA-emergency use authorized tests per member per month without prior authorization through December 2023. When you get FDA-authorized COVID-19 antigen test kits at a network pharmacy, there is zero cost to you as long as you go to the network pharmacy counter, present your member ID card and ask to have the product submitted to OptumRx. If you purchase tests and submit your receipt for reimbursement, you may be reimbursed only at the pharmacy’s negotiated rate depending on your plan. There is a $48 per month plan coverage limit, you pay all costs over $48 per month. So, you may not receive the full reimbursement for what you initially paid out of pocket.
Medicare coverage of test kits
Coverage through Medicare ended when the COVID-19 public health emergency (PHE) ended on May 11, 2023.
Where to get test kits
You can get one of the FDA-authorized COVID-19 test kits below at any network pharmacy at no cost to you. Just go to the pharmacy counter, show your member ID card, and ask to have the product submitted to OptumRx. You can also order test kits online, but you will be responsible for paying shipping charges and you will need to submit for reimbursement for the costs of the tests. If you purchase tests and submit your receipt for reimbursement, you may be reimbursed only at the pharmacy’s negotiated rate depending on your plan. So, you may not receive the full reimbursement for what you initially paid out of pocket.
Coverage includes at-home COVID-19 antigen test kits authorized by the Food and Drug Administration (FDA). The most common tests are brands BinaxNOW™, CLINITEST®, Flowflex™, i-Health®, InteliSwab™, On/Go™, QuickVue® and At-home test kits (Roche).
How to get reimbursed for test kits
If you purchase an FDA-authorized over-the-counter COVID-19 test kit at other stores or online retailers, or if you paid out-of-pocket for a test kit on or after January 15, you can submit a request for reimbursement. You may be reimbursed only at the pharmacy’s negotiated rate depending on your plan. So, you may not receive the full reimbursement for what you initially paid out of pocket.
Please submit your claim within one year of your purchase date. Reimbursement will be available through the end of the emergency health period.