(Updated 11/15/2022)

Following is the claim form and instructions for getting reimbursed for the COVID-19 at-home test kit(s) you purchased. For faster processing, you are instructed to mail in the completed reimbursement form directly to our pharmacy benefit partner, MedImpact. See complete instructions and mailing address on the form. 

A few important points to remember:

• • Have your CCHP Member ID card ready
  • Complete only one claim form per member
  • Members may be reimbursed up to $12 per test. Please note, some test kits may contain more than one test.
  • When submitting for multiple members with original receipt(s), enclose multiple forms that go with the receipt(s)
  • Each covered person, ages 2 years and older, is eligible for up to eight (8) at-home over-the-counter COVID-19 tests with NDCs with Emergency Use Authorization (EUA), per 30 days. For example, a family of four could receive up to 32 tests per 30 days. Please note, the test kits are reimbursable every 30 calendar days. For example, if you purchase 8 test kits on 11/1/22, you will be eligible for reimbursement for test kits purchased on 12/2/22 or later.

For any questions, please contact CCHP Member Services by phone: 1-888-775-7888 (M-Su 8:00 am-8:00 pm) or email MemberServices@CCHPHealthPlan.com

For any future test kits or testing needs, consider the options we have provided for your convenience. These options require no upfront out-of-pocket costs – you just need to show your CCHP Member ID card. Click Here to See Options.

Thank you for being a CCHP Member.

Download Claim Form Here