PROVIDER RESOURCES

Welcome, providers. Use the forms below to submit eligibility and renewal questionnaires on behalf of your patients participating in the GLP-1 Benefit Program.

Questionnaire Forms

First Time Questionnaire

Submit the initial eligibility questionnaire for a patient who is new to the GLP-1 Benefit Program. Required before a patient can participate or receive reimbursement.

Open First Time Questionnaire

Renewal Questionnaire

Submit the renewal questionnaire for a patient continuing in the GLP-1 Benefit Program. Required to renew eligibility and maintain program participation.

Open Renewal Questionnaire

Internal Appeal

Only complete this appeal form if you have already completed the First-Time Questionnaire or Renewal Questionnaire and received a "Denial Decision."

Open Internal Appeal

External Review

Only complete this appeal form if you have: (1) completed the First-Time Questionnaire or Renewal Questionnaire and received a Denial Decision, and (2) submitted two Internal Appeal Forms, each resulting in a Denial Decision.

Open External Review

Before You Submit

Ensure appropriate forms are selected and all required fields are completed accurately before submitting.
Incorrect form selection or incomplete form submission may result in delays in processing.

For any questions, please email support@therxcard.com or call 800-396-2688 between 9-5:30 ET Monday through Friday.