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 highmarkanswers.com.
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 highmarkanswers.com.
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.
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.
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.
OTC testing used for employment purposes is not covered under this mandate.
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.
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.
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All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.
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Highmark Blue Cross Blue Shield or Highmark Blue Shield are Medicare Advantage HMO, PPO, and/or Part D plans with a Medicare contract. Enrollment in these plans depends on contract renewal.
®Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Benefits and/or benefit administration may be provided by or through the following entities, which are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company.
PA: Your plan may not cover all your health care expenses. Read your plan materials carefully to determine which health care services are covered. For more information, call the number on the back of your member ID card or, if not a member, call 866-459-4418.
Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield.
West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Visit our website to view the Access Plan required by the Health Benefit Plan Network Access and Adequacy Act. You may also request a copy by contacting us at the number on the back of your ID card.
Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield.
Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
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