CurrentFidelis CarePolicy N/A

COVID-19 At-Home Test Covered Products

Lists specific over-the-counter COVID-19 at-home antigen test products (with NDCs) covered for Fidelis Care Child Health Plus (CHP) and Essential Plan members. Applicable to coverage and billing for those products.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 At-Home Test Covered Products

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse the listed OTC COVID-19 at‑home antigen test products (by brand and NDC) for coverage and billing for Child Health Plus and Essential Plan members as specified.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10+distinct covered product listings (including multi-pack variants)

NDCs providedproducts listed include National Drug Codes

CHP & Essentialplans explicitly named as covered

Covered Products and Criteria

Covered products list

Covered OTC at-home antigen tests: The listed OTC at-home COVID-19 antigen test products (by brand and NDC) are covered for Child Health Plus and Essential Plan members as specified in the list.

No additional coverage criteria or clinical indication requirements are provided.

This policy provides an itemized list of covered over‑the‑counter (OTC) COVID‑19 at‑home antigen test products and their National Drug Codes (NDCs) for Fidelis Care Child Health Plus and Essential Plan members. No explicit exclusions or non‑covered test types are specified in the document; the listing is limited to named OTC at‑home antigen products and does not define additional clinical indication, frequency, or laboratory certification restrictions.

Indications for Coverage

NDCs and Product Codes

Covered NDCs / ProductsNDCCovered

11877-0011-40	BinaxNOW COVID-19 AG Home Test NDC
14613-0339-72	QuickVue At-Home COVID-19 Test NDC
50010-0224-31	CareStart COVID-19 Home Test NDC
56362-0005-89	iHealth COVID-19 Rapid Test NDC
82607-0660-26	Flowflex COVID-19 AG Home Test NDC
82607-0660-27	Flowflex COVID-19 AG Home Test NDC
95893-0533-17	COVID-19 OTC Antigen 2-Pack NDC
95893-0774-90	COVID-19 OTC Antigen 1-Pack NDC
08337-0001-58	InteliSwab COVID-19 Rapid Test NDC
CHP Only	Product listed as 'CHP Only' (coverage limited to Child Health Plus)

Policy Summary

PayerFidelis Care

PolicyCOVID-19 At-Home Test Covered Products

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse the listed OTC COVID-19 at‑home antigen test products (by brand and NDC) for coverage and billing for Child Health Plus and Essential Plan members as specified.

SourceLink

On This Page

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Provider Billing and Action Items

Note

Provider Action: None Specified

No provider-specific actions are required under this policy. The document does not specify any provider prior authorization, ordering, or billing denial conditions for at‑home OTC COVID‑19 antigen tests.

Prior Authorization

There are no prior authorization requirements stated for these at‑home OTC antigen tests.

Step Therapy

No step therapy requirements or sequencing rules are provided for these at‑home OTC antigen tests.

Billing Rule

Covered OTC At‑Home COVID‑19 Antigen Tests (selected products)

The document lists specific OTC COVID‑19 at‑home antigen test products and their NDCs covered for Child Health Plus and Essential Plan members.

Ordering and Provider Restrictions

Note

No ordering provider restrictions

No ordering provider restrictions are specified; coverage is defined by the listed products and NDCs rather than by who orders the test.

OTC at‑home tests are listed by product name and NDC for Child Health Plus and Essential Plan coverage.

Frequency and Quantity Limits

Frequency limits

Frequency limitsNo frequency or quantity limits are specified in this document for covered OTC at‑home COVID‑19 antigen tests.

Coverage periodCoverage applies to the products listed for Child Health Plus (CHP) and Essential Plan members; no time-based limits are stated.

Per‑member limitsDocument does not specify per‑member per‑period limits (e.g., per day, week, or month).

Pack/kit variantsMulti‑pack and single‑pack variants (e.g., 1‑pack and 2‑pack NDCs) are listed without separate frequency caps.

Exclusions and Non-Covered Items

The inventory and policy text do not identify any tests, product types, or clinical indications that are explicitly excluded from coverage. In other words, no tests or indications are listed as not covered within this document; coverage is limited to the specific OTC at‑home antigen products detailed in the covered products list.

Background and Scope

The document lists specific over‑the‑counter COVID‑19 at‑home antigen test products by brand and NDC for coverage under Child Health Plus (CHP) and Essential Plan: BinaxNOW COVID‑19 AG Home Test — NDC 11877‑0011‑40; QuickVue At‑Home COVID‑19 Test — NDC 14613‑0339‑72; CareStart COVID‑19 Home Test — NDC 50010‑0224‑31; iHealth COVID‑19 Rapid Test — NDC 56362‑0005‑89; Flowflex COVID‑19 AG Home Test — NDCs 82607‑0660‑26 and 82607‑0660‑27; COVID‑19 OTC Antigen 2‑Pack — NDC 95893‑0533‑17; COVID‑19 OTC Antigen 1‑Pack — NDC 95893‑0774‑90; and InteliSwab COVID‑19 Rapid Test — NDC 08337‑0001‑58. One entry is labeled CHP Only to indicate coverage limited to Child Health Plus members.

Definitions

OTC at-home antigen test

DefinitionAn OTC at‑home antigen test is a rapid antigen test designed for at‑home use to detect SARS‑CoV‑2, listed here by brand name and NDC for coverage purposes.

Examples (covered products)BinaxNOW COVID‑19 AG Home Test (NDC 11877-0011-40); QuickVue At‑Home COVID‑19 Test (NDC 14613-0339-72); CareStart COVID‑19 Home Test (NDC 50010-0224-31).

Additional covered examplesiHealth COVID‑19 Rapid Test (NDC 56362-0005-89); Flowflex COVID‑19 AG Home Test (NDCs 82607-0660-26 and 82607-0660-27); InteliSwab COVID‑19 Rapid Test (NDC 08337-0001-58).

Pack variantsCOVID‑19 OTC Antigen 2‑Pack (NDC 95893-0533-17) and 1‑Pack (NDC 95893-0774-90) are included in the listed products.