PATIENTS CAN GAIN ACCESS TO THE

EVERSENSE® CGM SYSTEM WITH THE

PATIENT ASSISTANCE PROGRAM FROM ASCENSIA DIABETES CARE

 

 

Eversense® 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 90 days with world-class accuracy.*1

 

PATIENT ASSISTANCE PROGRAM

Provides relief to eligible patients with a reduction of out-of-pocket costs. Eligible patients pay the first $100 of their identified out-of-pocket costs, and Ascensia may cover up to $300 of the balance of these costs. The patient is responsible for any remaining balance.

 

ELIGIBLE PATIENTS COULD SAVE UP TO $1,200 PER YEAR ON THEIR EVERSENSE SENSOR SUPPLY.

 

HOW PATIENTS CAN ENROLL IN THIS PROGRAM:

  • The Patient Assistance Program will be applied to eligible patients who purchase Eversense® 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 with supporting documentation. The patient will be notified by their Strategic Fulfillment Partner or Ascensia Field Support Specialists on the appropriate steps for enrollment.

 

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

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

† If a patient does not have insurance and will be paying cash for the product, they may be eligible for the Eversense Patient Assistance Program. Limitations and Restrictions may apply.

‡ Maximum savings limit applies; and will vary depending on patient out of pocket costs. Please see Program Terms, Conditions, and Eligibility Criteria. Limitations and restrictions apply.

Eligible patients with U.S. commercial health insurance may receive up to $300 US dollars towards out-of-pocket costs per Eversense 90 day sensor procedure. Void where prohibited. Ascensia Diabetes Care reserves the right to terminate the program at any time without notice.

Reference: 1. Christiansen, M. P. et al. (2019). A prospective multicenter evaluation of the accuracy and safety of an implanted continuous glucose sensor: The PRECISION study.

Diabetes Technology & Therapeutics, 21(5), 231-237. doi:10.1089/dia.2019.0020


ENROLLMENT FORM:

TO SEE IF YOU ARE ELIGIBLE FOR THE EVERSENSE PATIENT ASSISTANCE PROGRAM, COMPLETE THIS ENROLLMENT FORM AND PROVIDE AN EXPLANATION OF BENEFITS AND SUBMIT ONLINE.

SEE BELOW FOR TERMS AND CONDITIONS. CERTAIN RESTRICTIONS APPLY.

PLEASE COMPLETE THE APPROPRIATE SECTION(S) OF THE FORM AND CHECK ALL BOXES BELOW TO CONFIRM YOUR AGREEMENT WITH THE TERMS AND CONDITIONS, PATIENT AUTHORIZATION AND PATIENT ATTESTATIONS.

PATIENT INFORMATION

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Contact Information
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TERMS AND CONDITIONS

  • The Eversense Patient Assistance Program (the “Program”) is offered by Ascensia Diabetes Care US Inc. (“Ascensia”) to eligible patients who have a valid prescription for the Eversense 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 Sensor, which shall also include the accompanying Eversense Smart Transmitter; or (ii) a replacement Eversense Sensor without an accompanying Eversense Transmitter (the Eversense Sensor and the Eversense Transmitter collectively referred to as the “Eversense Products”).
  • Patient must have a valid prescription for the Eversense 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; or (v) 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 Products. The benefit available under the Program is valid for the patient’s out-of-pocket cost for the Eversense 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 Products.
  • Patient must pay the first $100 of out-of-pocket cost for the Eversense Products. 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 Products, less $100, up to a maximum of $300 per the Eversense Products.
  • In addition to this form, patient must provide a valid and accurate EOB from patient’s commercial health insurance within 90 days of the date of service for patient to receive the Program benefit; provided the date of service is on or after May 15, 2021. The EOB must reflect the patient’s out-of-pocket cost for the Eversense Products and submission of the claim by the patient’s provider for the cost of the Eversense Products.
  • Patient agrees not to seek reimbursement for all or any part of the Eversense 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 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 submitting this form, I authorize my healthcare provider to use and/or disclose my protected health information (PHI) related to the Eversense® Sensor, Eversense Transmitter and Adhesive Patches, and/or Eversense® 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 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 and agree that (a) I am the person whose name appears on this form, (b) I intend to sign this document electronically, and (c) I agree that my electronic signature is the same as a handwritten signature for the purposes of validity, enforceability and admissibility.