NC Medicaid-enrolled pharmacy providers are reminded that point-of-sale (POS) billing for FDA-authorized over-the-counter (OTC) COVID-19 tests dispensed for use by NC Medicaid beneficiaries in a home setting became effective Jan. 10, 2022. The test can be dispensed with or without a prescription issued by an active NC Medicaid-enrolled provider. Implementation of POS claim submission for OTC COVID-19 tests started Jan. 10, 2022, for NC Medicaid Direct. All five managed care plans have implemented POS coverage of the tests mirroring the coverage of Medicaid Direct. POS claims submission start dates varied across the plans.
NC Medicaid will cover one kit per claim per date of service. A maximum of eight tests is allowed every rolling 30 days. The eight total tests could be mixed and matched between one-test kits or two-test kits to get a total of eight tests.
A State Standing Order has been issued for the OTC COVID-19 test for home use. Another option is to submit the claim using the pharmacy National Provider Identifier (NPI) unless the test is prescribed by a Medicaid-enrolled provider.
Pharmacies must follow the National Council for Prescription Drug Programs (NCPDP) standard and use the National Drug Code (NDC) found on the package. Reimbursement is at an NDC-specific State Maximum Allowable Cost (SMAC). Copayment will not apply.
Covered test kits with the SMAC are listed below:
CONTACT
NC Medicaid Contact Center: 888-245-0179