Form

RedSail Advantage®

Please provide the following information before June 25, 2024 so we can opt-out your pharmacy from the XCOPRI Refill Care Goal program.

Pharmacy Name*

NPI Number*

NCPDP Number*

Multiple Pharmacy Locations?

Please provide NPI/NCPDPs for each location that needs to opt-out.

First Name*

Last Name*

Email*

Phone Number*

Yes, please Opt-Out my pharmacy from the XCOPRI Refill Care Goal program.