HHSC will include COVID-19 at-home test kits as a Medicaid, Children’s Health Insurance Program (CHIP), Healthy Texas Women (HTW), Kidney Health Care (KHC), and Children with Special Health Care Needs (CSHCN) pharmacy benefit beginning January 3, 2022, in fee-for-service (FFS) and no later than January 17, 2022, in managed care. An adjudicated pharmacy claim is required for reimbursement of a COVID-19 at-home test. Clients may obtain COVID-19 at-home test kits from a Medicaid-enrolled retail pharmacy with or without a prescription from a prescribing provider.
The list of covered tests is below and will be available as part of the Formulary Product search on the VDP website. HHSC selected these products based on their status under the Emergency Use Authorization (EUA) from the U.S. Food & Drug Administration.
Clients may obtain a maximum quantity of 4 tests per calendar month. Prescriptions can be processed using single packs (1 test) or multi-pack test kits (2 tests), equaling a total of 4 at-home COVID-19 tests per month. As an 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.
No Prescription
When there is no prescription, pharmacies must use the information below for pharmacy claims:
- 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 any applicable refills may not exceed the benefit limit of 4 tests per calendar month.
Allowable Test Kits
| COVID-19 Test-Kit Name | NDC | Package Size | Max Price per NDC/Test Kit |
|---|---|---|---|
| InteliSwab COVID-19 Rapid Test | 08337-0001-58 | 2 tests | $41.38 |
| QuickVue At-Home OTC COVID-19 Test | 14613-0339-37 | 1 test | $41.38 |
| QuickVue At-Home OTC COVID-19 Test | 14613-0339-72 | 2 tests | $41.38 |
| BinaxNOW COVID-19 AG Card | 11877-0011-29 | 1 test | $41.38 |
| BinaxNOW COVID-19 AG Card Home Test | 11877-0011-33 | 1 test | $41.38 |
| BinaxNOW COVID-19 AG Self Test | 11877-0011-40 | 2 tests | $41.38 |
| Everlywell COVID-19 Test Home Collection Kit DTC | 51044-0008-42 | 1 test | $51.33 |
In fee-for-service 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 units 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 (see chart above) with no dispensing, delivery, or incentive fees. This new pharmacy benefit will not count against a FFS client’s 3-prescription-per-calendar-month limit.