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’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.

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. Please check NJMMIS.com for updates.

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.