HHSC allows COVID-19 at-home test kits at no cost to people enrolled in Medicaid, CHIP, CSHCN, HTW, and KHC. HHSC allowed the benefit for clients in fee-for-service Medicaid, CSHCN, HTW, and KHC as of Jan. 3, 2022, and since Jan. 17, 2022, for clients enrolled in managed care.
Clients may obtain COVID-19 at-home test kits from a Medicaid-enrolled retail pharmacy with or without a prescription from a prescribing provider. An adjudicated pharmacy claim is required for reimbursement of a COVID-19 at-home test.
A list of products is available through the Formulary search (txvendordrug.com/formulary/formulary-search). Users can search by product name, the 11-digit NDC, or click the "COVID-19 vaccine" checkbox to review details about each test kit. HHSC selected these products based on their status under the Emergency Use Authorization (EUA) from the U.S. Food and Drug Administration.
Clients may obtain a maximum quantity of 4 tests per calendar month. Pharmacies can process prescriptions using single packs (1 test) or multi-pack test kits (2 tests), equaling a total of 4 at-home COVID-19 tests per month. For example:
- 1 single pack kit (1 test) allows 4 kits per calendar month
- 1 multi-pack kit (2 tests) allows 2 kits per calendar month
Quantities dispensed can be up to the maximum allowed of 4 tests per calendar month with or without a prescription. Pharmacies must submit a separate claim for each transaction of a COVID-19 test kit.
Without a Prescription
Pharmacies must use the information below for pharmacy claims without a prescription. Refer to the Claims Billing (B1) Transaction payer sheets for specific transaction, segment, and field requirements.
- NPI: 3070440003 in the "Prescriber ID" field (411-DB)
- Provider last name: Test Kit Prescriber
- Provider first name: COVID
- Address: HHSC
- License: CTK001
Refills are not authorized when there is no prescription.
With a Prescription
When processing a prescription from a prescriber for a COVID-19 test kit, the prescribed quantity and applicable refills may not exceed the maximum benefit limit of 4 tests per calendar month.
In FFS Medicaid, HTW, KHC, and CSHCN, pharmacy claims exceeding the maximum quantity of 4 tests per calendar month will reject with NCPDP reject code "76" (Plan limitation exceeded) and the message "Only 4 COVID-19 tests allowed per calendar month" in the "Additional Message Information" field (526-FQ).
COVID-19 at-home test kits will have a reimbursement rate maximum price with no dispensing, delivery, or incentive fees and will not count against an FFS client's 3-prescription-per-calendar-month limit.