COVID-19 Over-the-Counter Test Reimbursement Form

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Complete this form for each covered member
You can submit up to 8 tests per covered member per month
Tests must be FDA-authorized
Tests must be purchased on or after January 15, 2022
Your commercial plan will reimburse you up to $12 per test. Medicare member reimbursement amount per test may vary by Medicare plan.
Reimbursement requests take up to 4-6 weeks to process
Questions? Call the number located on the back your member ID Card

Fields marked with an asterisk

are required.

Are you filling this form out for yourself or someone else that is not a Medicare member?

Yes

No, I am the authorized representative for a Medicare member.

First name

Middle initial

Last name

Date of birth

mm/dd/yyyy

Phone number

555-555-5555

name@email.com

Re-enter email

name@email.com

Address

Address 2

P.O. boxes are not allowed

City

State

5-digit ZIP code

Member ID

BIN

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

PCN

Rx Group/Submitted Group ID number