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To verify your benefits, please call WebTPA Customer Service directly at 877-697-2299.

Co-Pay Discount Request

Please be advised ... We can only assist you with questions related to Chronic Disease Case Management.

Please give us 2-3 business days to review your information and to contact you.

**Please Note ...
•	A request must be made for each doctor (specialist)
•	The request for the co-pay reduction must be renewed yearly
•	This request does not replace the referral

* indicates required information

*Member ID: (as shown on your ID card i.e. 764001234-01)	-
*Date of Birth: (mm/dd/yyyy)	/ /