RENEWAL QUESTIONNAIRE

Renewal Questionnaire Form

Member First Name *

Member Last Name *

Member Date of Birth *

Member Social Security # (9 digits, No dash or Space) — required unless Employer Employee ID + Dependent Number are provided

Member Email *

Member Phone *

Enter at least 10 digits

Member Address Line 1 *

Member Address Line 2

Member City *

Member State *

Member ZIP Code *

Drug Name *

Quantity *

Day Supply *

Have you adhered to a reduced-calorie diet AND increased physical activity? *

Have you experienced 5% or more weight loss from baseline? *

Secure submission. Your information is sent securely, and any files you upload are stored privately and available only to authorized reviewers. Please enter only the information needed to review this request.

Please read the following information prior to completing this form.

You are required to fill out this form to renew your eligibility for the program.
You will not be able to participate in the program or seek reimbursement for GLP-1 drugs without having first completed this form and having been approved.
Submission will be reviewed and you will be notified of a decision within 3 days.
Once you have received approval email, you will be able to continue your credit toward the purchase of GLP-1 drugs.