WELLNESS KIT CONTENTS

Looking to Cut Back or Quit Nicotine?

Support doesn’t have to be all-or-nothing.
Check what options may be available to you in under a minute.

Complete Your Request — It’s Quick & Secure

This short form is required to begin eligibility review, coverage review, and provider review. Provider review is required before any supplies can ship.

(1/5)

Please enter in MM-DD-YYYY format

Where Should We Send Your NRT Kit?

(2/5)

Tobacco Use History
(This helps our pharmacist choose the right support for you)
(3/5)

If none, please type none
Please select all that apply
If none, type none

Helping You Get the Right Care
(Safety questions required before nicotine replacement therapy)
(4/5)

Please list any medication or supplements you are taking.
If none, type none
If none, please type none
If none, please type none

Last Step! Authorization:
(5/5)

Warning: Before taking any medications or over-the-counter drugs, consult a physician for a thorough evaluation. Always seek the advice of a physician or other qualified healthcare provider with any questions regarding a medical condition. Do not take medication if you have a known allergy to it.

SMS Consent Options (required by A2P 10DLC):

Clear
By opting in and signing we have permission to verify current medication list provided with Sure Script

This questionnaire is available in multiple languages upon request.
¿Necesita el formulario en español? Pídaselo al farmacéutico.
هل تحتاج النموذج باللغة العربية؟ اطلبه من الصيدلي.

HOW IT WORKS

Takes about 60 seconds.
No pressure.

Many people look for ways to cut back or make changes, but don’t always know where to start.
This quick check helps determine what support options may be available based on your responses.

Quick Check

Complete your quick check

Answer a few simple questions to get started.

Review Check Icon

Our Team reviews your request

Your information is securely reviewed.

Support Delivered to Your Door con

Support Delivered to Your Door

If approved, support is arranged for delivery.

Support options are designed to be flexible and fit into your routine.
You don’t have to make big changes all at once.

Kit Contents

This may be a good fit if you:

  • Live in California

  • Are looking for flexible support options

  • Prefer a simple, at-home process

  • Want to take things at your own pace

Delivered to House

Designed to make access simple from home

StayWell US works with licensed providers and pharmacies to help connect individuals with available support options across California.

  • Must live in California

  • Must meet basic program requirements

Eligibility and benefits are subject to review.

Helping California Families

Your information is reviewed securely | Next steps are provided after submission | No obligation to complete

A Trusted California Partner

Serving California Families Since 2020

FAMILY ON BEACH

StayWell US works with licensed providers and pharmacies to help connect individuals with available support options.

Designed to make access simple, secure, and accessible from home.

HIPAA BADGE

This program is available to eligible California Medi-Cal members. Requests are reviewed by a licensed provider. Approval is not guaranteed. If approved, Medi-Cal may be billed for covered products, and supplies are shipped to the member at no cost. Stay Well US is not a government agency and is not affiliated with or endorsed by the State of California or Medi-Cal. No items are shipped until eligibility information is submitted and the request is reviewed.

COMPANY

CUSTOMER CARE