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
  • 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.

Requestor Information

Member Information



P.O. boxes are not allowed

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.