Mail-in claim forms allow you to submit a claim for multiple members with one form. Nondiscrimination Notice and Foreign Language Assistance, Summary of Preventive and Contraceptive Services, must be purchased on or after January 15, 2022, used to identify the potential COVID-19 infection, will be self-administered with results that can be self-read, will not be resold, given or supplied to persons other than family members covered under the same policy, The purchase receipt documenting the date of purchase and price, UPC** cut-out from the over-the-counter COVID-19 test packaging, Signed, completed attestation confirming and acknowledging that the purchased over-the-counter at-home COVID-19 test meets eligibility guidelines. Use the doctors, labs and facilities in your BCBSTX health plans provider network for: File is in portable document format (PDF). Reimbursement will be in the form of a paper check in U.S. currency and mailed to the address provided on your Retail Prescription Drug Overseas Claim Form. endstream endobj 462 0 obj <>/ProcSet[/PDF]>>>>stream 2023 Blue Cross Blue Shield Association. Additional details about at-home COVID-19 testing can be found on the Blue Cross Blue Shield website. Y0118_22_062A_C 02082022 endstream endobj 469 0 obj <>/Subtype/Form/Type/XObject>>stream You can also log in to the SydneySM Health mobile app, go to Claims, and choose Submit a Claim. You may have to pay out of pocket at the time of purchase, but keep your receipt to submit a claim online. Health Benefits Election Form (SF 2809 Form) To enroll, reenroll, or to elect not to enroll in the FEHB Program, or to change, cancel or suspend your FEHB enrollment please complete and file this form. // stream How can I resolve a problem with my PPO or HMO claim? What you need to know about the disease and our commitment to ensuring you have access to the right care at the right time. You can also go to any other in-network retail pharmacy and purchase the test kits at the pharmacy counter2. Your plan covers up to 8 tests every 30 days per covered person. To receive reimbursement for over-the-counter/at-home tests with a receipt dated May 11, 2023 or prior, members with Independence Blue Cross prescription drug coverage should submit documentation through ibx.com. If this happens, you can pay for the test and then submit a claim for reimbursement. If you purchase a test kit that includes two rapid tests, that will count as two of your eight covered tests. State and Federal Privacy laws prohibit unauthorized access to Member's private information. Thats why we are committed to ensuring our members who are dealing with a diagnosis of COVID-19 can easily access the care they need.. If you do not have an itemized receipt, you must send us the barcode (UPC code) from your test (s) packaging. New User? // ]]>, // /ProcSet[/PDF]>>>>stream You will be going to a new website, operated on behalf of the Blue Cross and Blue Shield Service Benefit Plan by a third party. The list will be updated as new FDA-authorized tests become available. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Youll go to a page that explains the form and has a link to download it. follow the latest CDC guidance for isolation. Even though the Public Health Emergency is ending May 11, 2023, our commitment to helping you live your healthiest life will not change. Read Full Story Audience Communities Your member ID card is your key to using your medical plan benefits. You will be reimbursed via check, mailed to the address we have on file within 30 days of Blue Cross Blue Shield of Arizona (BCBSAZ) receiving your reimbursement information. hb``g``````pD8 D8: I=3011\o`;!A ;\/0fpi$ ([!x Contact your local health department to learn about free COVID-19 testing locations or pickup sites. 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