Premera Bluecross COVID-19 Testing Coverage Update

Coverage Criteria for SARS-CoV-2 Testing

inv-01: Diagnostic Testing (Covered)

Diagnostic Testing is reimbursed when ALL of the following are met:

Diagnostic test approval: The test is approved, cleared, or authorized under sections 510(k), 513, 515, or 564 of the Federal Food, and Cosmetic Act; the developer has requested or intends to request Emergency Use Authorization (EUA) under section 564; is developed in and authorized by a State that has notified HHS of its intention to review tests intended to diagnose COVID-19; or is another test the Secretary of HHS determines appropriate in guidance.

Provider determination: An attending provider has made an individualized determination that the test is medically necessary for diagnosis or treatment of COVID-19.

Attending provider as defined in applicable federal guidance.

Intended use: The test is used to diagnose and/or treat an individual suspected of having a coronavirus infection.

inv-02: Surveillance and Screening Testing (Not reimbursed)

Not covered when used solely for surveillance/screening/data collection or non-diagnostic purposes:

Surveillance/Screening/Other non-diagnostic uses: Testing performed solely for data collection, analysis, or public health surveillance (including determination of prior infection) and testing for return-to-work or -school, occupational, travel, public health screening, and vaccine accommodation.

Results not used for individual diagnosis/treatment are nonreimbursable; documentation should identify the purpose of the test and be available for review.

inv-03: Over-the-Counter (OTC) Tests

Policy stance on OTC/self-administered tests:

OTC member-submitted claims general rule: Self-administered and self-read at home/elsewhere over-the-counter (OTC) COVID-19 tests will not be reimbursed as member-submitted claims.

Policy archived effective February 6, 2026; historical exception: OTC tests with purchase dates through May 11, 2023 were processed for member-submitted reimbursement (up to 8 tests per 30 days) with documentation requirements such as proof of purchase and test package information.

Testing performed solely to support return-to-work or return-to-school requirements, occupational screening, travel clearance, public health screening programs, or vaccine accommodation is not considered medically necessary for individual diagnosis or treatment and is not covered under any Company plan. Documentation in the member's medical record should identify the purpose of the COVID-19 test and be available for review upon request.

Surveillance-only testing and screening testing that are not intended to provide individualized diagnosis or guide treatment decisions are not reimbursed. Tests performed solely for population-level data collection, analysis, or public health surveillance—where results are not used to diagnose or treat an individual—are considered nonreimbursable.

Covered Indications

inv-21: Diagnosis of current SARS-CoV-2 infection when an attending provider determines the test is medically necessary for diagnosis or treatment

Attending provider determination: Diagnosis of current SARS-CoV-2 infection when an attending provider determines the test is medically necessary for diagnosis or treatment.

An attending provider must make an individualized determination of medical necessity as defined in applicable federal guidance.

Coding and Diagnosis Codes

Molecular test codesCPTCovered

0202U	Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
0223U	Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
0225U	Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected
0240U	Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected
0241U	Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), influenza A, influenza B, respiratory syncytial virus (RSV)), upper respiratory specimen, each pathogen reported as detected or not detected
87635	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique
87636	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique
87637	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique

Antigen test codesCPTCovered

87426	Infectious agent antigen detection by immunoassay technique (e.g., EIA, ELISA, FIA, IMCA), qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV-2)
87428	Infectious agent antigen detection by immunoassay technique, qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV-2) and influenza virus types A and B
87449	Infectious agent antigen detection by immunoassay technique, qualitative or semiquantitative; multiple-step method, not otherwise specified, each organism
87811	Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Antibody and neutralizing antibody test codesCPTCovered

0224U	Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed
86328	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
86413	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative
86769	Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
86408	Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); screen
86409	Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); titer
0226U	Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum

OTC test kit codeHCPCS

K1034

Provision of COVID-19 test, nonprescription self-administered and self-collected use, FDA approved, authorized or cleared, one test count

ICD-10 diagnosis codesICD-10

U07.1	COVID-19
Z20.822	Contact with and suspected exposure to COVID-19
Z03.89	Encounter for observation of other suspected diseases and condition rule out
Z11.52	Encounter for screening for COVID-19

Other USR/CDC test codesCPT

U0001	CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel
U0002	2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC

OTC member reimbursement window

Reimbursement cutoff (purchase date)Member-submitted claims for OTC self-tests were reimbursed only for tests purchased through May 11, 2023; purchases on or after May 12, 2023 are not reimbursed.

Historical processing requirementsFor OTC tests purchased prior to May 12, 2023, members submitted a separate claim form per covered family member with required documentation (procedure code, place of service HOME, diagnosis code, receipt/shipping proof, barcode/photo of test package).

Effective dates for OTC codesHCPCS K1034 effective April 4, 2022 through May 11, 2023; C0019 effective January 15, 2022 through May 11, 2023.

Policy change notePolicy removed reimbursement for OTC tests purchased on or after May 12, 2023 in response to the end of the federal COVID-19 Public Health Emergency (PHE).

Provider Responsibilities and Documentation

Denial Risk

Diagnostic testing medical necessity and FDA authorization

Diagnostic testing for COVID-19 is reimbursed only when the test has FDA approval/clearance/authorization (including EUA or equivalent State authorization) and an attending provider has made an individualized determination that the test is medically necessary to diagnose or treat the member. The test must be used to diagnose and/or treat an individual suspected of having coronavirus infection.

Test must be approved, cleared, or authorized under applicable sections of the Federal Food, Drug, and Cosmetic Act (e.g., 510(k), 513, 515, 564) or be a State-authorized test recognized by HHS guidance.
An attending provider (per federal guidance) must document an individualized medical necessity determination for diagnosis or treatment.
Test purpose must be diagnostic and/or to inform treatment for a suspected SARS-CoV-2 infection.

Documentation Required

Documentation and receipts for OTC/home tests

Ordering and Authorization

Step Therapy

Ordering must be by attending provider with individualized determination

An attending provider — a licensed individual acting within their scope of practice and responsible for providing care — must make an individualized determination of medical necessity and order the diagnostic test accordingly.

Order must reflect individualized medical necessity for diagnosis or treatment of COVID-19.

Frequency Limits and OTC Allowances

OTC self-tests — historical allowance

Historical allowance periodSelf-administered, self-read OTC tests purchased January 15, 2022 through May 11, 2023 were eligible for reimbursement as member-submitted claims.

Quantity limitCovered up to 8 individual OTC tests per participant/enrollee per 30-day period for purchase dates Jan 15, 2022 through May 11, 2023.

Documentation required for claimsMembers had to provide purchase receipt/shipping receipt showing amount paid, specific test purchased, and total number of individual tests; photo/copy of the test package barcode; and, for online orders, claims were held until tests were received.

Claim submission detailsMember-submitted claims required a separate claim form for each covered family member and inclusion of the applicable procedure/HCPCS code (e.g., K1034/C0019) and a HOME place of service code.

Not Covered

Self-administered, over-the-counter (OTC) COVID-19 tests that are self-read at home or elsewhere are not reimbursed when submitted as member claims. In addition, testing conducted solely for surveillance, screening, or other non-diagnostic purposes (including return-to-work/school, occupational, travel, and public health screening) is not covered. For all clinical testing, providers should document the purpose of the test in the member's medical record and retain documentation for review.

Definitions

Diagnostic Testing — definition and intended use

DefinitionDiagnostic testing: testing primarily intended for individualized diagnosis or treatment of current infection in individuals who are symptomatic or who have had known or suspected recent exposure to SARS-CoV-2.

Intended useUsed to diagnose and/or guide treatment for an individual suspected of having coronavirus infection; includes molecular (RNA) and antigen (protein) tests.

Provider requirementAn attending provider must make an individualized determination that the test is medically necessary for diagnosis or treatment to qualify for reimbursement.

Screening Testing — definition for asymptomatic screening

DefinitionScreening testing: testing to identify people who are not exhibiting symptoms and who have not had a known or suspected exposure to SARS-CoV-2, used to detect persons who may be contagious.

Background

Diagnostic viral tests for SARS-CoV-2 fall into two primary categories: molecular tests and antigen tests. Molecular tests (for example, RT-PCR) detect viral RNA and are generally more sensitive, making them the preferred method to confirm active infection. Antigen tests detect viral proteins and typically provide faster results but have lower sensitivity compared with molecular methods. The policy distinguishes tests intended for individualized diagnosis and treatment from those intended for screening or population surveillance; only tests used to diagnose or guide treatment of an individual are eligible for reimbursement.

OpenPayer

COVID-19 Testing: Diagnostic, Surveillance and Over-the-Counter