• COVID-19 iNFORMATION

     

    Beginning January 15, 2022, individuals with private health insurance coverage or covered by a group health plan who purchase an over-the-counter COVID-19 diagnostic test authorized, cleared, or approved by the U.S. Food and Drug Administration (FDA) will be able to have those test costs covered by their plan or insurance. 

    The below standard pharmacy paper claims form has been adapted to be more specific to the COVID at-home testing coverage. 

     

    • The following sections of the form need to be completed:
      • Member information
      • Cardholder information
      • Prescription (Rx) Claim information
        • Using the UPC in place of the requested NDC number
        • The Physician NPI number does NOT need to be completed         
    • The Pharmacy Information section does NOT need to be completed
    • A retail/ pharmacy receipt needs to be attached to the paper claims form

     

    For more information on how to get your At-Home Over-The-Counter COVID-19 Test for Free go to: https://www.cms.gov/how-to-get-your-at-home-OTC-COVID-19-test-for-free

    Prescription Drug Claim Form

    COVID Home Test Prescription Drug Claim Form-Sample

    COVID-19 Testing Kit Coverage