Over-the-counter (OTC) COVID-19 tests covered for Apple Health (Medicaid) clients

Washington State Health Care Authority sent this bulletin at 01/26/2022 03:17 PM PST

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Over-the -counter (OTC) COVID-19 tests covered for Apple Health (Medicaid) clients

Apple Health (Medicaid) covers over-the-counter (OTC) COVID-19 tests with or without a prescription for clients. An adjudicated pharmacy claim is required for reimbursement of an OTC COVID-19 test. Pharmacies may not bill for test administration of an OTC COVID-19 test; these tests should be used by the patient in the home setting.

To bill the OTC COVID-19 tests, pharmacies must follow the NCPDP standard and use the national drug code (NDC) or universal product code (UPC) found on the package.

No prescription

When there is no prescription:

For clients in managed care, contact the client's managed care plan for billing instructions.
For fee-for-service clients, pharmacies must use the following prescriber information:
- Prescriber ID Qualifier (466-EZ): 01
- Prescriber ID (407-D7): 5123456787
- Prescriber last name: OTC PRODUCT

Limitations

The following limits apply for OTC COVID-19 tests billed with or without a prescription:

A total of 12 tests, per client, per month
If additional tests are needed:
- For clients in managed care, contact the client's managed care plan
- For fee-for-service clients, pharmacy providers can submit a prior authorization request to HCA. Please see the Prescription Drug Program billing guide for information on how to obtain a authorization.

Claims can be processed using single packs (1 test) or multi-pack test kits (2 tests), equaling a total 12 OTC COVID-19 tests per month. As an example:

1 Single pack kit (1 test) – allows 12 kits per calendar month
1 Multi pack kit (2 tests) – allows 6 kits per calendar month

Additional Information

For more information about COVID-19 testing, see the Apple Health (Medicaid) clinical policy and billing for COVID-19 FAQ and the Apple Health (Medicaid) COVID-19 testing clinical policy.

For updated information regarding COVID-19, see HCA’s Information about novel coronavirus (COVID-19) webpage.

For additional questions, please email applehealthpharmacypolicy@hca.wa.gov

About the Health Care Authority (HCA)

The Washington State Health Care Authority (HCA) is committed to whole-person care, integrating physical health and behavioral health services for better results and healthier residents.

HCA purchases health care for more than 2.5 million Washington residents through Apple Health (Medicaid), the Public Employees Benefits Board (PEBB) Program, the School Employees Benefits Board (SEBB) Program, and the COFA Islander Health Care Program. As the largest health care purchaser in the state, we lead the effort to transform health care, helping ensure Washington residents have access to better health and better care at a lower cost.

Please do not reply directly to this message. For more information, visit the HCA website, where you'll also find contact information.

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The Washington State Health Care Authority (HCA) complies with all applicable federal and Washington state civil rights laws and is committed to providing equal access to our services. Visit HCA’s website to view complete nondiscrimination statements.