EXTERNAL REVIEW

External Review Form

Member First Name *

Member Last Name *

Member Date of Birth *

Member Social Security # (9 digits, No dash or Space) *

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 *

Weight in Pounds *

Range: 50-800 lbs

Height in Inches *

Range: 36-96 inches (3-8 ft)

BMI (Body Mass Index) *

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

Please fill out this form to request an independent external review of your GLP-1 Benefit Program eligibility determination.
Your request will be reviewed by an independent reviewer and you will be notified of a decision within the timeframe specified by your plan.
Please ensure all information is accurate and complete before submitting.