This form is to request reimbursement for U.S. Food and Drug Administration (FDA) authorized over-the-counter at-home COVID-19 tests that may be covered under your medical plan purchased on or after January 15, 2022.
Over-the-Counter (OTC) At-home COVID-19 Test Reimbursement Form
![United Healthcare](https://www.pef.org/wp-content/uploads/2022/03/AtHome.jpg)
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