CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

At-home OTC COVID-19 test kit coverage

This document governs Neighborhood Health Plan of Rhode Island coverage of FDA-approved over-the-counter at-home COVID-19 test kits for members, specifying quantity limits and acquisition process.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAt-home OTC COVID-19 test kit coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 15, 2022

Next Review DateN/A

Key ActionMembers must present their Neighborhood Member ID at a participating pharmacy to receive up to 8 FDA-approved at‑home COVID-19 test kits at no cost per 30 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8kits per member

30 daysperiod

noprescription required

Coverage Criteria for At‑Home OTC COVID‑19 Test Kits

inv-01: Coverage criteria

Covered when ALL of the following are met

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAt-home OTC COVID-19 test kit coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 15, 2022

Next Review DateN/A

Key ActionMembers must present their Neighborhood Member ID at a participating pharmacy to receive up to 8 FDA-approved at‑home COVID-19 test kits at no cost per 30 days.

SourceLink

On This Page

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Member eligibility and test type: Member is enrolled in a Neighborhood plan AND test is an FDA-approved over-the-counter at-home COVID-19 test kit

Quantity and timing: Member receives no more than 8 home OTC test kits within any 30-day period8 per 30 days

Acquisition method: Member purchases the kit in-store at a participating pharmacy and presents Neighborhood Member ID to receive at no cost

No prescription required

Members who obtain at-home COVID-19 test kits outside of participating pharmacies or who do not present their Neighborhood Member ID at the time of purchase are not guaranteed access to the no-cost benefit described in this policy. The policy requires that members purchase the kit in-store at a participating pharmacy and present their Neighborhood Member ID card to receive the kit at no cost; failure to meet these acquisition conditions may result in the member being charged for the test kit.

No prescription or prior authorization is required for covered at-home tests. Coverage is limited to FDA-approved, over-the-counter, at-home COVID-19 test kits obtained through the participating pharmacy process described above, and to the quantity limits set by the plan. Situations that do not meet those requirements (for example, tests purchased elsewhere or without Member ID presentation) are outside the acquisition method that enables the no-cost provision.

Coding and Quantity Limits

Covered CPT Codesmixed

No codes listed

Quantity limit

Quantity limitUp to 8 over-the-counter, FDA-approved, at-home COVID-19 tests per member

Time periodLimit applies per 30-day period (every 30 days)

Aggregate ruleEach member may receive no more than 8 home OTC test kits within any 30-day window

Prescription requirementNo prescription or prior authorization required to receive covered kits

Provider / Member Actions and Requirements

Note

No prescription required

No prescription or prior authorization required — Members may obtain up to 8 FDA‑approved over‑the‑counter (OTC) at‑home COVID‑19 tests every 30 days.

Up to 8 FDA‑approved OTC at‑home COVID‑19 tests per member every 30 days
No prescription or prior authorization required

Documentation Required

Member identification requirement

Members must present their Neighborhood Member ID card at a participating pharmacy to receive the at‑home OTC COVID‑19 test kit at no cost.

Failure to present Neighborhood Member ID at the participating pharmacy may result in not receiving the kit at no cost

Note

Provider action callout

Background

This notice explains Neighborhood Health Plan of Rhode Island’s temporary coverage of FDA-approved, over-the-counter, at-home COVID-19 diagnostic test kits during the public health emergency. Effective January 15, 2022, the plan will cover the cost of up to 8 at-home OTC test kits per member in any 30-day period without a prescription, provided the member purchases the kit in-store at a participating pharmacy and presents their Neighborhood Member ID card to receive the kit at no cost.

Definitions

At-home OTC COVID-19 test kit — definition

DefinitionFDA-approved over-the-counter diagnostic tests intended for home use

Where usedCovered when purchased in-store at a participating pharmacy and presented with Member ID

Coverage conditionOnly FDA-approved OTC at-home COVID-19 test kits are described as covered

Covered Indications

inv-12: Home use for COVID-19 detection by members — Only FDA-approved OTC at-home tests are covered.

Covered when ALL of the following are met

Test type: Test is an FDA-approved over-the-counter at-home COVID-19 test

Only FDA-approved OTC at-home tests are covered

Frequency Limits

FDA-approved OTC at-home COVID-19 test kits

Covered kit count8 FDA-approved OTC at-home COVID-19 test kits

Per-member limitPer member allowance of up to 8 kits

PeriodAllowance resets every 30 days

Ordering Requirements

Step Therapy

No clinician order required — in‑store purchase and ID presentation

No clinician order is required; members purchase the test kit in‑store at a participating pharmacy and present their Neighborhood Member ID to obtain it at no cost.

Not Covered

Tests that are not FDA-approved, over-the-counter, at-home COVID-19 test kits, or kits that are obtained without purchasing in-store at a participating pharmacy and presenting the member’s Neighborhood Member ID, are not covered under the no-cost provision described in this notice. Coverage described here applies only when the specified acquisition and identification conditions are met.