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
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Requestor Information


Member Information


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555-555-5555

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name@email.com

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Insurance Information


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.