COVID-19 Over-the-Counter Test Reimbursement Form

  • Complete this form for each covered member
  • You can submit up to 8 tests per covered member per month for tests purchased from January 15, 2022 through May 11, 2023. Claim must be submitted within 365 days after the purchase.
  • Tests must be FDA-authorized
  • Tests must be purchased from January 15, 2022 through May 11, 2023
  • Your commercial plan will reimburse you up to $12 per test for purchases through May 11, 2023. Medicare member reimbursement amount per test may vary by Medicare plan. Applies to purchases from January 15, 2022 through May 11, 2023.
  • Reimbursement requests take up to 4-6 weeks to process.
  • Reimbursement requests for purchases made on or after May 12, 2023 may be rejected as many plans have discontinued coverage with the expiration of the Public Health Emergency. See your benefit summary for details as some states and plans may have continued coverage for test kits after May 11, 2023.
  • Questions? Call the number located on the back your member ID Card.
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Requestor Information

Member Information



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Insurance Information

Please provide what is on your member card, failure to provide at least one of these fields can lead to failure in claim approval.