Please read the following information prior to completing this form.
You are required to fill out this form 120 days after your first approval.
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.
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