RENEWAL QUESTIONNAIRE

Renewal Questionnaire Form

Member First Name *

Member Last Name *

Member Date of Birth *

Member Employer Employee ID

Member Dependent Number

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 *

Do you have Prediabetes, Hypertension, Kidney Disease, Heart Failure or any Cardiovascular diseases? *

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

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

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.