Reimbursement Request Form

You may submit a request for reimbursement using this form for any eligible GLP-1 drugs purchased after January 1, 2026.
Please attach a copy of your paid receipt as well as a picture of your drug label to this form using the "Upload Receipt & Rx Label" link below the form. Submission without these items will not be approved.
Reimbursement requests are not permitted if you have used HSA to pay for your GLP-1 drug. Please note that you must use a payment method other than a HSA card if you wish to receive direct reimbursement for these drugs under this program.
Submission will be reviewed and, if approved, a check will be issued and mailed to the address provided here within 14 days of submission.
Please enter your name as you want it printed on your reimbursement check.
Please enter your mailing address to which you would like your reimbursement check mailed to.