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COVID-19 information for our clinical partners

 News & updates

May 6 Authorization requirements previously relaxed to resume May 17
May 6 Remdesivir approved as treatment for kids under 12
April 16 Bebtelovimab fights COVID subvariant now dominant in Massachusetts
March 16 COVID-19 treatments available across Massachusetts


May 6 Authorization requirements previously relaxed to resume May 17
May 6 Remdesivir approved as treatment for kids under 12
April 16 Bebtelovimab fights COVID subvariant now dominant in Massachusetts
March 16 COVID-19 treatments available across Massachusetts
March 11 Medicare sequestration to resume April 1, 2022
March 2 Auth requirements and credentialing procedures continue to be relaxed
February 10 New resources for at-home COVID-19 testing
January 31 At-home COVID test coverage for members began Jan 15 UPDATED!
January 27 FDA Changes: Some Monoclonal Antibody Treatments No Longer Covered
January 18 At-home COVID test coverage for members began Jan 15

+ 2021

+ 2020


 Vaccines and treatments

COVID-19 vaccine billing

For vaccine billing, administration codes, and more information, please refer to our COVID-19 Temporary payment policy.

FDA-approved pharmaceutical treatment

Blue Cross covers drugs with FDA-approval and those with Emergency Use Authorization for COVID-19 at no cost to our members throughout the duration of the public health emergency. For more information on pharmaceutical treatment, please refer to our COVID-19 Temporary payment policy.

Investigational drugs

Covered investigational drugs
Several drugs that have shown early benefit in clinical trials are under investigation as potential treatments for COVID-19. Blue Cross covers the antiviral therapy and immunomodulators when used outside a clinical trial for patients who are in an inpatient hospital setting and require treatment beyond respiratory support. This is at the discretion of their treating provider.

Non-covered investigational drugs
Blue Cross does not cover drugs that have not demonstrated improvement in patient outcomes in early studies or are not recommended for use outside of the clinical trial setting by the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), or Department of Public Health (DPH) guidelines. The following drugs are not covered outside of the clinical trial setting:

  • Blood-derived products (such as SARS-CoV-2 immunoglobulins, mesenchymal stem cells)
  • Antiviral therapies or immunomodulators without published supporting evidence (such as lopinavir/ritonavir, and other HIV protease inhibitors)
  • Other therapies currently under investigation without published supporting evidence

Cognitive rehabilitation

Per state mandate Chapter 260 of the Acts of 2020—Patients First Act, cognitive rehabilitation for cognitive impairment resulting from COVID-19 is covered in the outpatient setting. Providers should document all of the following for coverage:

  • Cognitive impairments resulting from COVID-19 that were either clinically diagnosed or diagnosed through PCR/antigen testing 
  • Patient symptoms that impair daily functioning and are unlikely to resolve on their own over time 
  • Patient symptoms that are expected to improve with cognitive rehabilitation

Inpatient cognitive rehabilitation is covered when the patient meets the inpatient level of care criteria. For more details, see our medical policy 660: Cognitive Rehabilitation.

FDA-approved pharmaceutical treatment

Blue Cross covers drugs with FDA-approval and those with Emergency Use Authorization for COVID-19 at no cost to our members throughout the duration of the public health emergency. For more information on pharmaceutical treatment, please refer to our COVID-19 Temporary payment policy.

Investigational drugs

Covered investigational drugs
Several drugs that have shown early benefit in clinical trials are under investigation as potential treatments for COVID-19. Blue Cross covers the antiviral therapy and immunomodulators when used outside a clinical trial for patients who are in an inpatient hospital setting and require treatment beyond respiratory support. This is at the discretion of their treating provider.

Non-covered investigational drugs
Blue Cross does not cover drugs that have not demonstrated improvement in patient outcomes in early studies or are not recommended for use outside of the clinical trial setting by the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), or Department of Public Health (DPH) guidelines. The following drugs are not covered outside of the clinical trial setting:

  • Blood-derived products (such as SARS-CoV-2 immunoglobulins, mesenchymal stem cells)
  • Antiviral therapies or immunomodulators without published supporting evidence (such as lopinavir/ritonavir, other HIV protease inhibitors)
Other therapies currently under investigation without published supporting evidence

Cognitive rehabilitation

Per state mandate Chapter 260 of the Acts of 2020—Patients First Act, cognitive rehabilitation for cognitive impairment resulting from COVID-19 is covered in the outpatient setting. Providers should document all of the following for coverage:

  • Cognitive impairments resulting from COVID-19 that were either clinically diagnosed or diagnosed through PCR/antigen testing 
  • Patient symptoms that impair daily functioning and are unlikely to resolve on their own over time 
  • Patient symptoms that are expected to improve with cognitive rehabilitation
Inpatient cognitive rehabilitation is covered when the patient meets the inpatient level of care criteria. For more details, see our medical policy 660: Cognitive Rehabilitation.

 Testing

Commercial members: HMO, POS, PPO, and Indemnity

Provider-ordered COVID-19 tests

What’s covered
Blue Cross covers:

  • Medically necessary reverse transcription-polymerase chain reaction (RT-PCR) or antigen testing to diagnose COVID-19 when ordered by a health care provider as part of an individualized assessment in accordance with current standards of medical practice. For RT-PCR or antigen testing, in accordance with the Centers for Disease Control (CDC) and the MA Department of Public Health guidelines, covered scenarios include (but are not limited to):
    • Symptoms consistent with COVID-19, such as fever, cough, shortness of breath, chills, muscle pain, sore throat, anosmia, and gastrointestinal distress
    • Asymptomatic patients with direct exposure and/or close contact to another individual with a confirmed case of COVID-19
      • Close contact is defined by the CDC as someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period* starting from 2 days before illness onset until the time the patient is isolated (or, for asymptomatic patients, 2 days prior to test specimen collection)
    • Symptomatic or asymptomatic patients who require testing prior to a medical procedure or surgery
    • Admission to a facility – including but not limited to a hospital operated or licensed by the Department of Public Health or Mental Health, a long-term acute care hospital, or a skilled nursing facility

* Individual exposures added together over a 24-hour period (e.g., three 5-minute exposures for a total of 15 minutes).

All covered tests must be FDA-approved or have Emergency Use Authorization, or the developer must have requested, or intends to request Emergency Use Authorization.

What’s not covered
PCR or antigen testing and serological testing are not covered for:

  • General screening purposes (such as return-to-work, or attending school, day care, or camp)
  • Public health or surveillance purposes
  • Periodic or serial testing of asymptomatic individuals (examples include congregate housing, such as dormitories and residential facilities, and occupational safety)
    • Tests that have been denied FDA approval, an Emergency Use Authorization from the FDA, or laboratories that have not submitted an Emergency Use Authorization request within a reasonable timeframe
    • Member transportation to or from testing sites (unless the member meets requirements for ambulance services)
    • Screening eligibility to donate plasma (for serologic testing)

At-home tests

As of January 15, 2022, we cover up to eight FDA-authorized self-administered at-home tests per member, per month for commercial members for personal or diagnostic use, without cost or prior clinical assessment for the duration of the federal public health emergency.

  • Commercial members can use any pharmacy in the Express Scripts network to receive FDA-authorized tests for $0. In-network pharmacies include CVS, Walgreens, Walmart, and many others. Members can receive up to eight tests per month, or four 2-test kits.
  • Members may also order up to eight FDA-approved tests per member, per month from Express Scripts mail order pharmacy. See the tests that we cover by visiting our At-Home COVID-19 Tests page.
  • Members who buy a different test or shop at an out-of-network retailer can get reimbursed up to $12 per test, for up to eight tests a month by submitting a reimbursement form.
  • Coverage applies to test kit purchases made on or after January 15, 2022 and is not retroactive.

Medicare Advantage members

Provider-ordered COVID-19 tests

PCR or antigen tests
The  use of PCR or antigen testing to diagnose COVID-19 infection is covered for FDA-approved tests when ordered by any health care professional authorized under state law. In keeping with CMS guidance and for the duration of the COVID-19 public health emergency, Blue Cross covers, without a health care professional’s order:

  • The cost of one diagnostic test for COVID-19, and
  • One diagnostic test each for influenza virus or similar respiratory condition for Medicare members.

These tests are covered when performed in conjunction with a COVID-19 test needed to obtain a final COVID-19 diagnosis. Subsequent tests require the order of an authorized health care professional.

Antibody testing
Serologic testing for the presence of antibodies for known or suspected current or prior COVID-19 infection is covered for FDA-approved tests when ordered by any health care professional authorized under state law.

At-home tests

As of January 15, 2022, Blue Cross reimburses Medicare Advantage members up to $12 per FDA-authorized, self-administered at-home tests for up to eight tests per month, without the need for prior clinical assessment. Eligible Medicare Advantage members can complete the Medicare Advantage COVID-19 At-Home Test Reimbursement form. Blue Cross will cover these tests until December 31, 2022.

As of April 4, 2022, Original Medicare* also covers up to eight over-the-counter COVID-19 tests each calendar month, at no cost. This coverage continues until the COVID-19 public health emergency (PHE) ends. Members may need to show their red, white, and blue Medicare card to get the no-cost over-the-counter COVID-19 tests (even if they have another card for their health plan). See a list of eligible pharmacies and participating health care providers.

* The Medicare benefit is not covered by Blue Cross Blue Shield of Massachusetts.

Federal Employee Program (FEP) members

Antibody tests

The Federal Employee Program covers COVID-19 testing and antibody testing without cost or prior clinical assessment, including for:

  • Travel purposes
  • Asymptomatic members
  • Pre-surgical testing for elective and non-elective procedures
  • Return-to-work

Note: There are no limits on frequency of testing.

At-home / over-the-counter tests

For information on coverage for our FEP members, visit www.fepblue.org/coronavirus-updates/over-the-counter-tests.

 Telehealth (telephone calls and video visits)

Coverage

Our Telehealth – Medical Services and Telehealth - Mental Health payment policies detail coverage and billing guidelines. For more information, see our Telehealth page.

For Federal Employee Program (FEP) members,  there is no member cost for all telehealth services (COVID-19 and non-COVID-19 related) received through the Teladoc® network. Members can register for Teladoc by visiting fepblue.org/coronavirus. For providers not in the Teladoc network, the applicable cost share applies (unless COVID-19 related).

 Administrative changes & other updates

Claims for laboratory services including COVID-19 testing

The ordering clinician NPI is a required field on your claim to indicate that the lab test is medically necessary. This change is described in our April 30, 2021 News Alert, "Lab claims must include ordering clinician NPI starting July 1."

Adjustments to Medicare Advantage reimbursement

The Protecting Medicare and American Farmers from Sequester Cuts Act reinstated the Medicare payment adjustment known as “sequestration,” effective April 1, 2022. From April 1, 2022 to June 30, 2022, CMS will apply a 1% payment adjustment. Beginning July 1, 2022, CMS will apply a 2% payment adjustment. This policy update applies to all medical providers.

 Member cost (copayments, co-insurance, and deductibles)

Out-of-pocket COVID-19 costs are waived

For the duration of the public health emergency, we have removed copayments,
co-insurance, or deductibles for all medically necessary COVID-19 related care at:

  • Doctors' offices
  • Urgent care centers
  • Emergency departments

This follows Centers for Disease Control and Prevention (CDC) and Massachusetts Department of Public Health (DPH) guidelines. Any medically necessary treatment for COVID-19 is covered under a member's health plan within the United States or internationally.

We’re also removing member cost share (copayments, co-insurance, and deductibles) for COVID-19-related inpatient care at both in- and out-of-network acute care facilities for our fully insured members.

Note: Self-insured accounts design/customize their plans and benefits and may require inpatient cost share.

For FEP members, we waive cost for inpatient acute care hospitals, inpatient rehab facilities, long-term acute care hospitals, and skilled nursing facilities for COVID-19 related services.

COVID-19 diagnostic testing is covered

We're covering the full cost of FDA-approved COVID-19 diagnostic testing with no member cost as long as the test is ordered by a health care provider and meets CDC guidelines, for the duration of the public health emergency.

  • Testing for Medicare members COVID-19 is covered
    Medicare Part B (medical insurance) covers testing for COVID-19, with no cost share when ordered by a provider.
  • COVID-19 out-of-pocket costs are waived
    For members in our Medicare Advantage HMO Blue and PPO Blue, Managed Blue for Seniors, and Medex®' plans, we’ve waived the cost share related to medically necessary COVID-19 testing, counseling, vaccinations, and treatment at doctor’s offices, ERs, and urgent care centers, in accordance with CDC and Massachusetts DPH guidelines.

Inpatient and outpatient observation level of care for COVID-19 diagnoses

We waive member cost for medically necessary inpatient and outpatient level of care hospital services when the claim includes a COVID-19 diagnosis. This applies to in- and out-of-network services.

We do not waive member cost for care received in skilled nursing facilities. This policy applies to all Blue Cross Blue Shield of Massachusetts members.

Note: Employers who are self-insured may choose to waive cost for their employees.

*Blue Plan members receiving care in Massachusetts are covered according to their Home plan’s benefits and coverage.

Member questions

Members can call our dedicated coronavirus help line at 1-888-372-1970.

Contact us

(Medical and Mental Health) Network Management and Credentialing Services
1-800-316-BLUE (2583)

Dental Network Management
1-800-882-1178

Links & resources