Pharmacy Coverage of Over-the-Counter Diagnostic Antigen Tests for COVID-19

The South Carolina Department of Health and Human Services (SCDHHS) will reimburse for Food and Drug Administration-approved coronavirus disease 2019 (COVID-19) over-the-counter (OTC) tests for home use. SCDHHS will reimburse SCDHHS-enrolled pharmacy providers for these tests as authorized within sections 9811 and 9821 of the American Rescue Plan Act, and further delineated within the August 30, 2021, letter from the Centers for Medicare and Medicaid Services (SHO# 21-003).   

Pharmacy Coverage of OTC COVID-19 Tests

OTC tests will be covered without prior authorization or cost share with a quantity limit of eight tests per 30-day period. Prescriptions for tests are not required.  A one-time override will be allowed per 30-day period (up to a maximum of 10 tests per 30-day period).  

The per test (unit) rate of reimbursement will not exceed $12 ($24 for a box of two tests). To be eligible for reimbursement, claims must be submitted as a pharmacy claim. For billing purposes, pharmacies will use one of the five SCDHHS-recognized OTC test kits in the table below.  

SCDHHS will reimburse for dates of service on or after Jan. 1, 2022. The Medicaid program cannot pay a member directly for a test they have purchased on their own; therefore, SCDHHS will only reimburse providers for OTC COVID-19 tests.

SCDHHS will also update guidance regarding coverage of additional COVID-19 OTC tests as required.

Questions regarding fee-for-service claims processing should be directed to Magellan Medicaid Administration’s Call Center at (866) 254-1669. The call center is available 24 hours/day.

For questions regarding pharmacy benefits related to the managed care organizations (MCOs) serving South Carolina Healthy Connections Medicaid members, please contact the MCO directly.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

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