COVID-19 At-Home Test Reimbursement
Eligible members can get reimbursed for the cost of FDA-authorized, at-home COVID-19 tests. Members can request
reimbursement for up to eight tests each month, for purchases made on or after January 15, 2022. Submit a separate form for each
covered member, including dependents.
001379602 (1/22)
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Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity.
ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711).
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que gura en su tarjeta de identicación (TTY: 711).
ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).
COMPLETE THIS FORM AND EMAIL IT OR SEND IT TO:
COVIDTestClaims@BCBSMA.com or Blue Cross Blue Shield of Massachusetts, Local Claims Department, PO Box 986030, Boston, MA 02298.
SUBSCRIBER INFORMATION (POLICYHOLDER)
ID NUMBER ON SUBSCRIBER ID CARD
(including rst 3 characters)
SUBSCRIBER'S LAST NAME FIRST NAME MIDDLE
INITIAL
ADDRESS – NUMBER AND STREET CITY
STATE ZIP CODE EMPLOYER’S NAME
CLAIM INFORMATION
MEMBER'S LAST NAME FIRST NAME MIDDLE
INITIAL
DATE OF BIRTH
CLAIM IS FOR (CHOOSE ONE AND COLOR IN THE ENTIRE BOX):
q SUBSCRIBER (POLICYHOLDER) q SPOUSE (OF POLICYHOLDER) q EX-SPOUSE q DEPENDENT (UP TO AGE 26)
q OTHER (SPECIFY): _____________________________________________
Important Information:
• This form can be used for tests purchased from January 15, 2022 through January 22, 2022. An updated submission form will be available on January 23, 2022.
• Keep copies of receipts in case we request them from you.
• Blue Cross Blue Shield of Massachusetts will make a reimbursement decision within 30 calendar days of receiving a completed request form.
• Reimbursement is sent to the member's address on le with Blue Cross. Reimbursement may be considered taxable income, so you should consult your tax advisor.
Certication and Authorization (This form must be signed and dated below.)
I certify that the information provided in support of this submission is complete and correct, and that I have not previously submitted for these purchases.
I understand that Blue Cross Blue Shield of Massachusetts may require proof of payment for a reimbursement decision. I authorize the release of any information about
purchases to Blue Cross Blue Shield of Massachusetts. By submitting this claim for reimbursement, you are attesting it was purchased for personal use, not for employment
purposes, and will not be be resold.
SUBSCRIBER’S OR MEMBER’S SIGNATURE: ___________ ___________ _________________________ DATE: ___________
NAME OF RETAILER
DATE OF
PURCHASE
AMOUNT
PAID
BRAND NAME
1
2
3
4
5
6
7
8
Tests purchased in a multi-pack count as multiple tests, and must be listed individually in the spaces provided below.
For example, if you paid $20 for a two-pack of tests, you’ll need to enter the information on two separate lines, at $10 each.
SAVE YOUR RECEIPTS, AND FILL OUT THE FOLLOWING:
