YOUR PASS TO SAVE ON THE ONLY 6-MONTH* CGM

PAYMENT ASSISTANCE & SIMPLE SAVINGS

 

Eversense E3 is the only long-term CGM system. It has an advanced sensor that sits comfortably just under the skin of the upper arm and monitors patients’ glucose levels for up to
6 months with exceptional accuracy over 6 months (MARD 8.5%**).

 

The EVERSENSE® PASS program

can help make the EVERSENSE® E3 Continuous Glucose Monitoring System more affordable for you – now and in the future!

 

HELPS ELIGIBLE PATIENTS MORE AFFORDABLY
ACCESS THE EVERSENSE® E3 CONTINUOUS
GLUCOSE MONITORING SYSTEM

 

 

HOW PATIENTS CAN REDEEM THESE OFFERS:

  • The Eversense PASS Program Assistance Program will be applied to eligible patients who purchase Eversense E3 CGM directly through a participating Strategic Fulfillment Partner. Patients will be informed of eligibility by the Strategic Fulfillment Partner when discussing out-of-pocket costs.
  • If purchasing through a Non-Participating Strategic Fulfillment Partner, the patient will need to complete and submit the form on reverse side with supporting documentation. The patient will be notified by their Strategic Fulfillment Partner or Ascensia Diabetes Therapy Associate on the appropriate steps for enrollment.

 

* For an overview of Eversense CGM safety information, please visit www.eversensediabetes.com/safety-info.

** Eversense E3 CGM System includes the Eversense E3 Sensor where sacrificial boronic acid (SBA) design modification was incorporated. In the PROMISE study, MARD of 8.5% was observed in the E3 Sensor, and MARD of 9.1% was observed in primary Sensor (which did not have SBA design modification).

Please visit www.ascensiadiabetes.com/eversense for limitations, restrictions, references and copyright information.

† The offers above only apply to the cost of the sensor and transmitter or sensor only. They do not cover the cost of the insertion procedure. Limitations and Restrictions may apply. Ascensia Diabetes Care reserves the right to change or terminate this program at any time without notice. The program benefit is capped per transaction. There may be instances in which patient out-of-pocket costs exceed what is detailed in INTRO and ONGOING offers.

The Eversense® E3 Continuous Glucose Monitoring (CGM) System is indicated for continually measuring glucose levels for up to 180 days in persons with diabetes age 18 and older. The system is indicated for use to replace fingerstick blood glucose (BG) measurements for diabetes treatment decisions. Fingerstick BG measurements are still required for calibration primarily one time a day after day 21, and when symptoms do not match CGM information or when taking medications of the tetracycline class. The sensor insertion and removal procedures are performed by a health care provider. The Eversense E3 CGM System is a prescription device; patients should talk to their health care provider to learn more.

 
For safety information, see https://www.ascensiadiabetes.com/eversense/safety-info/

Eversense, Eversense E3 Continuous Glucose Monitoring and the Eversense logo are trademarks of Senseonics, Incorporated. Ascensia and the Ascensia Diabetes Care logo are trade marks and/or registered trademarks of Ascensia Diabetes Care Holdings AG. Android is a trademark of Google LLC. Apple Watch is a product of Apple, Inc., and may be separately purchased from an authorized Apple retailer. Apple Watch is not included with the Eversense CGM System. All other trademarks are properties of their respective owners and are used solely for informative purposes. No relationship or endorsement should be inferred or implied.


ENROLLMENT FORM:

See below for terms and conditions. Certain restructions apply. Please complete the appropriate sections(s) of the form and check all boxes to confirm your agreement with the terms and conditions, patient authorization and patient attestations.

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TERMS AND CONDITIONS

  • The Eversense® PASS (Payment Assistance and Simple Savings) (the “Program”) is offered by Ascensia Diabetes Care US Inc. (“Ascensia”) to eligible patients who have a valid prescription for the Eversense® E3 Continuous Glucose Monitoring System and may need financial assistance with out-of-pocket costs. This Program is limited to patients who meet the eligibility requirements set forth herein.
  • Patient must be requesting financial assistance for (i) the initial Eversense® E3 Sensor, which shall also include the accompanying Eversense® E3 Smart Transmitter; or (ii) a replacement Eversense® E3 Sensor without an accompanying Eversense® E3 Transmitter (the Eversense® E3 Sensor and the Eversense® E3 Transmitter collectively referred to as the “Eversense® E3 Products”).
  • Patient must have a valid prescription for the Eversense® E3 Products for an FDA-approved indication.
  • Patient must be 18 years or older.
  • The Program is not valid for patients covered under: (i) Medicaid (including Medicaid patients enrolled in a qualified health plan purchased through a health insurance exchange marketplace established by a state government or the federal government); (ii) Medicare; (iii) a Medicare Part D or Medicare Advantage plan (regardless of whether a specific prescription is covered); (iv) TRICARE; (v) residents of the state of MA; or (vi) any other state or federal healthcare program or medical or pharmaceutical benefit or assistance program ((i) through (v) collectively, “Government  Programs”). The Program is also not available where prohibited by law or by the patient’s health insurance provider. 
  • Patient must be a resident of the United States including Puerto Rico and the District of Columbia, subject to changes in state law(s).
  • Patient must have an out-of-pocket cost for the Eversense® E3 Products. The benefit available under the Program is valid for the patient’s out-of-pocket cost for the Eversense® E3 Products only. It is not valid for any other out-of-pocket costs (for example, office visit charges or procedural administration charges) even if such costs are associated with the administration of the Eversense® E3 Products.
  • Patient Responsibilites: INTRO offer: Patient must pay up to $99 for their initial Eversense® E3 Sensor and Transmitter. The benefit available under the Program is limited to the amount the patient’s commercial health insurance company indicates on the Explanation of Benefits (EOB) that the patient is obligated to pay for the Eversense® E3 products less $99 up to the maximum allowed by the program per purchase. ONGOING offer: Patient must pay up to $600 for their subsequent Eversense® E3 Sensor or Eversense® E3 Sensor & Transmitter combination. The benefit available under the Program is limited to the amount the patient’s commercial health insurance company indicates on the Explanation of Benefits (EOB) that the patient is obligated to pay for the Eversense® E3 products less $600 up to the maximum allowed by the program per purchase. SELF-PAY offer: The patient is responsible for the full out of pocket costs minus the Program benefit of $600 when purchasing the Eversense® E3 Sensor or Sensor and Transmitter without the support of commercial health insurance.
  • In addition to this form, patient must provide a valid and accurate EOB from patient’s commercial health insurance within 180 days of the date of service for patient to receive the Program benefit; provided the date of service is on or after April 1, 2022. The EOB must reflect the patient’s out-of-pocket cost for the Eversense® E3 Products and submission of the claim by the patient’s provider for the cost of the Eversense® E3 Products. For situations in which an EOB is not available (i.e. SELF-PAY or pharmacy benefit a detailed dealer invoice is sufficient).
  • Patient agrees not to seek reimbursement for all or any part of the Eversense® E3 Products from any other third party, and/or federal or state healthcare program. Patient agrees to and is responsible for reporting receipt of Program benefits to any insurer, health plan, or other third party who pays for or reimburses any part of the cost paid for by the Program, as may be required. This offer may not be redeemed for cash or
    anything else of value.
  • All information applicable to the Program requested on this form must be provided, and all certifications must be acknowledged. Patients who submit forms that are either modified or do not contain all of the necessary information and acknowledgements will not be eligible for benefits under the Program.
  • The Program is not insurance nor does it represent or constitute insurance of any kind. The monetary assistance under the Program is non-transferable, limited for each eligible patient, and may not be combined with any other offer.
  • The Program benefit cannot be combined with any other assistance program, free trial, discount, prescription savings card, or other offer.
  • Patient consents to their personal and health data being received, accessed, and/or shared by and between Ascensia and our contracted Program partners, solely for purposes of operating the Program for the patient (which includes assistance in (i) obtaining Eversense® E3 Products, and (ii) insurance coverage determinations through pre-authorization and appeal submissions).
  • Ascensia (either directly or through a contracted Program partner) reserves the right to rescind, revoke, or amend this Program without notice at any time. The Program is void where prohibited; rules and restrictions apply.

PATIENT AUTHORIZATION

By signing this authorization, I authorize my healthcare provider to use and/or disclose my protected health information (PHI) related to the Eversense® E3 Sensor, Eversense® E3 Transmitter and Adhesive Patches, and/or Eversense® E3 Insertion Tool Kit from my health records and insurance information to Ascensia Diabetes Care, and I further authorize Ascensia Diabetes Care to share this information with its third party service providers and authorized agents, as necessary for treatment and care coordination, to obtain insurance coverage, payment information and assistance, and reimbursement information for the Eversense® E3 Products. I consent to Ascensia Diabetes Care and/or its contracted partner contacting me by phone or text to provide reimbursement and payment information, discuss available products and services, and gather relevant information related to the Program. I understand that Ascensia Diabetes Care does not charge for any texting services, but my provider’s standard message and data rates may still apply. I understand that the information I authorize a person or entity to disclose may be shared with other people or entities and will no longer be protected by applicable federal or state privacy regulations. In carrying out these activities, Ascensia Diabetes Care and/or its authorized third party service providers may relay information to health insurer(s), receive information from health insurer(s), and communicate such information to my healthcare provider. I understand that this authorization is voluntary and that I may refuse to sign this authorization. I understand that I may revoke this authorization at any time provided that the information has not been disclosed. Information that has already been disclosed may be further disclosed once the authorization has been revoked. I understand that if I choose to revoke this authorization, I must do so in writing to the following email address:eversenseenrollment@ascensia.com or by calling customer service at 1-844-736-7348 available from 8:00AM – 12:00AM EDT Monday to Sunday. This authorization will remain in effect until revoked by me or until the end of my participation in the Program.

PATIENT ATTESTATION

By selecting “submit” I acknowledge that I am the person whose name appears on this form and that I am in agreement with all of the terms and attestations above. My handwritten or electronic signature are one and the same for purposes of validity, enforceability and
admissibility.