You can now submit claims for over-the-counter (OTC), at-home COVID-19 tests for Horizon NJ Health members. Horizon NJ Health is aligning with guidance from the New Jersey Division of Medical Assistance and Health Services (DMAHS) to cover eligible OTC, at-home COVID-19 tests.

Claim Billing

When submitting claims for OTC, at-home COVID-19 tests, pharmacies must:

• Send a standard NCPDP D.0 claim transaction through the member’spharmacy benefit.
• Report the National Provider Identifier (NPI) of the dispensing pharmacist in Field No. 411-DB within the NCPDP Claim Segment.
• Assign an original prescription number with zero refills and the National Product Code (NDC) for each test kit dispensed. Do not use the Universal Product Code (UPC).
• Provide a U&C price when a claim includes both prescription and OTC (nonprescription) items.

Claim Reimbursement

• Reimbursement for OTC, at-home COVID-19 test kits is limited to no more than two at-home SARS-CoV-2 test kits per date of service and no more than four OTC, at-home COVID-19 test kits per month, for a total of eight tests per month.
• Reimbursement for each test kit will be the lesser of the pharmacy’s network contract rate, the pharmacy’s usual and customary (U&C) price, or $25 for kits containing two tests and $12.50 for kits containing one test. In accordance with 42 C.F.R. § 447.512(b), pharmacies must provide a U&C price when submitting pharmacy claims that include both prescription and OTC (nonprescription) items. NJAC 10:51-1.10 defines U&C as the lowest price charged to the majority of the general public.
• Listed below are OTC, at-home test kits covered by Horizon NJ Health. Additional kits may be covered in the future.

  OTC Brand Name	NDC	Quantity of tests per kit	Reimbursement
  BD Veritor At-Home Covid-19 Test	08290256094	2	Up to $12.50 per test
  BinaxNOW COVID-19 Antigen Self-Test	11877001140	2	Up to $12.50 per test
  CareStart COVID-19 Antigen Home Test	50010022431	2	Up to $12.50 per test
  Celltrion Diatrust Covid-19 AG Home Test	06121076323	2	Up to $12.50 per test
  Clinitest Covid-19 Home Test	16490002597	2	Up to $12.50 per test
  COVID-19 Genabio Rapid Self Test Kit, 1	96852025431	1	Up to $12.50 per test
  COVID-19 Genabio Rapid Self Test Kit, 2	96852095300	2	Up to $12.50 per test
  iHealth Covid-19 AG At Home Test Kit	56362000589	2	Up to $12.50 per test
  Indicaid Covid-19 AG At Home Test Kit	60008040780	2	Up to $12.50 per test
  InteliSwab COVID-19 Rapid Test	08337000158	2	Up to $12.50 per test
  QuickVue At-Home COVID-19 Test	14613033972	2	Up to $12.50 per test
  Flowflex COVID-19 AG Test	82607066026	1	Up to $12.50 per test
  Flowflex COVID-19 Antigen Test	82607066027	2	Up to $12.50 per test

  If you have any questions, please call our Pharmacy Help Desk at 1-800-682-9094, extension 81016, weekdays, 8 a.m. to 5:30 p.m., Eastern Time (ET), and Saturday, 8 a.m. to 4:30 p.m., Eastern Time.

More Testing Options

The Biden-Harris Administration launched covidtests.gov‌ where residential households in the U.S. can order four free OTC, at-home tests. This option is available to all of our members, regardless of which health plan they have.