Submitting Pharmacy Claims for OTC, At-Home COVID-19 Test Kits
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.
When submitting claims for OTC, at-home COVID-19 tests, pharmacies must:
- Send a standard NCPDP D.0 claim transaction through the member’s pharmacy 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.
- 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. Please check NJMMIS.com for updates.
|OTC Brand Name||NDC||Quantity of tests per kit||Reimbursement|
|BinaxNOW COVID-19 Antigen Self-Test||11877001140||2||Up to $25|
|CareStart COVID-19 Antigen Home Test||50010022431||2||Up to $25|
|InteliSwab COVID-19 Rapid Test||08337000158||2||Up to $25|
|QuickVue At-Home COVID-19 Test||14613033972||2||Up to $25|
|Flowflex COVID-19 AG Test||82607066026||1||Up to $12.50|
|Flowflex COVID-19 Antigen Test||82607066027||2||Up to $25|
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.