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OTC COVID-19 Test Order Page

OTC COVID-19 Test Order Form

Sav-Rx is proud to support health plans in providing coverage for over-the-counter (OTC) COVID-19 testing.

Eligible participants under certain health plans are able to order OTC COVID-19 tests to be delivered directly to their doorsteps.

To see if your plan has this option, please type in your Group Number (listed on your ID card). Then click the 'Get Form' button. If your plan has this option, the form will appear.

To order your eight (8) OTC COVID-19 tests to be delivered directly to your doorstep, please fill out the form below.

There is no cost to you to place an order since your health plan covers the cost of OTC COVID-19 tests shipped directly to you.

Sav-Rx Group Number:

	Card Information
Sav-Rx Group Number:
Sav-Rx Card Number:
Cardholder First Name:
Cardholder Last Name:

	Patient Information
Patient First Name:
Patient Last Name:
Patient Date Of Birth:
Patient Relationship:

	Delivery Information
Delivery Address:
Address (cont):
City:
State:
Zip:
Phone:
Phone Type:
Email:
	Required

*This form will allow you to order eight (8) OTC COVID-19 tests per individual per calendar month. If you have already utilized your prescription benefit to purchase one or more OTC COVID-19 tests at a retail pharmacy this month, then you will need to wait until the next calendar month to order eight (8) tests. Your health plan covers at 100% a maximum of eight (8) OTC COVID-19 tests per individual per calendar month.

**Due to global supply chain issues, in stock is not guaranteed.