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) *

Please read the following information prior to completing this form.

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.

Unable to complete the online form?

If you or your provider are unable to fill out this form online, you may download the Word document version, complete it, and upload it using the link below.

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