Request At-Home COVID-19 Tests
Fill out the information below so that we can submit a request to your insurance for your at-home COVID-19 tests. If you are a Medicare or Medicaid member, please contact the pharmacy at (682) 708-3499 for assistance.
How many at-home tests do you need?
*
Please Select
2 Tests
4 Tests
6 Tests
8 Tests
Minimum order of 2 tests. Depending on the brand, you will receive 1 or 2 tests per pack.
Patient Information
Please fill in the information for the person who the tests are for. You must submit a separate request for each person on your insurance plan.
Name
*
First Name
Last Name
Address
*
Street Address
Unit, Apartment, etc. (Optional)
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Sex assigned at birth
*
Female
Male
Contact Information
We will text and email you about your order status. Standard data rates may apply.
Email
example@example.com
Mobile Phone
We will text and email you about your order status. Standard data rates may apply.
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Rx Insurance Information
All fields are required. However, Group ID and Rx PCN are only required if present on your insurance card.
Sample Rx Insurance Card
Your card may not look exactly like these examples.
Prescription Insurance Provider Name
*
Member ID
*
Rx BIN
*
Rx Group ID
If the primary cardholder has insurance through an employer, look for a Group ID.
Rx PCN
If Rx PCN is on the insurance card, enter it so we can bill the insurer.
What is your relationship to the insurance cardholder?
Self
Spouse
Child
Other
Submit Request
Should be Empty: