OTC Tests Online Request

Order At-Home COVID Tests FREE

MOST insurances are covering for free up to 8 at-home COVID tests per month per family member. We have created an online request form to request tests for you/your family.

Here is a list of some of the insurance plans and the respective BIN numbers on those cards/plans we have seen cover the tests (the list is not all inclusive and there may be others, as well).

Aetna: 610502 – Aetna Better Health: 610591 – BCBS Federal: 610239 – BCBS: 610455 – Benecard: 014179 – Capital RX: 610852 – Caremark/Health Partners: 004336 – Community Health: 610494 – Express Scripts: 003858 – Keystone First: 019595 – Medcohealth: 610014 – Medimpact: 003585 – Medicare B: Red, white, and blue card

Full Name of Person Requesting *

First Name Last Name

Email *

example@example.com

Birthdate *

Date

Phone Number *

Please enter a valid phone number.

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Are you on Medicare? *

Yes No

Please fill out the following insurance information from your insurance card *

RX BIN (6 Digit) RX PCN (Enter None, if none present)

Please enter your ID your Medicare Part B Card (Red, white, and blue card). COVID Test are only covered by Medicare Part B. *

Ex 1EG4-TE5-MK73

Please fill out the following insurance information from your insurance card *

ID Number RX Group Number (Enter None, if none present)

If you would like to request tests for any other immediate family members who have the same insurance information as you, please include each of their 1) First & Last Name (s) and 2) Date of Birth (s) herein. 8 tests will be provided per family member. IF your family member has different insurance, please complete a separate form for them. *

	Full Name	Date of Birth	Number of Tests	Relationship to patient
2
3

I have requested the pharmacy to provide the above listed OTC COVID-19 tests and attest to the following:

The test requested above are for personal ue for the indicated patient(s)
These tests are NOT for employer or travel purposes
I agree not to resale the tests provided under this covered benefit
The cost of these tests is not being covered by any other source
I have not requested OTC COVID -19 tests from another provider in the current calendar month
The tests requested above are for personal use for the indicated patient(s) These tests are not for employer or travel purposes

Signature of patient (or legal representative) *

Clear

Date *

Date

Attestation