Get For Diabetes Therapy: (ozempic (semaglutide)

Filling out the For Diabetes Therapy: (Ozempic (semaglutide) reimbursement request form is an important step towards securing coverage for your diabetes therapy. This guide will help you complete the form accurately and efficiently, ensuring all required information is provided.

Follow the steps to ensure a complete submission.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Make sure to print clearly and complete all sections of the form. Incomplete forms may lead to your application being declined.
3. The patient or plan member must fill out section A, providing their name, drug card number, date of birth, relationship to the employee or insured, and preferred method of contact for notification.
4. The physician must fill out section B, indicating the drug name (Ozempic (semaglutide)), strength, and dose, along with confirming eligibility criteria for reimbursement.
5. Ensure the physician provides their name, signature, license number, and contact details in the designated fields.
6. Review the completed form for accuracy, ensuring all mandatory fields are filled out correctly.
7. After verification, fax the form to 1-866-840-1509, or mail it to TELUS Health, 4141 Dixie Rd. P.O. Box 41154, Mississauga, Ont. L4W 5C9, as per your preference.
8. Retain a copy of the completed form for your records and allow two business days for a response once the form is submitted.

Complete your reimbursement request form online today to ensure you receive the necessary support for your diabetes therapy.