Application Form


To apply for participation in the Utah Insulin Savings Program, please complete and submit all of the information below. Once your information has been reviewed and verified, you will receive a secure email with your ID card and information regarding how to use the program. If you have questions, please call (801) 366-7551.


Applicant

Address

This email address is used to provide the applicant with confirmation of enrollment, an ID card, program information and general communications.

I hereby certify under penalty of perjury that I have read and understand the eligibility requirements To be eligible to participate, you must:
  • be a legal resident of the State of Utah;
  • be an individual who has been diagnosed with diabetes;
  • use insulin to treat diabetes; and;
  • not be an employee or dependent of an employee of the State of Utah with insulin related benefits covered through PEHP Health & Benefits.
 and I am eligible for the Utah Insulin Savings Program. I further agree to abide by any instructions and comply with any laws or rules enacted to receive the discounted rates for insulin. I understand that I will be liable for any discounts received for which I was not eligible.