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

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 Eversense® E3 Sensor, and 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; 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^® 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 or up to $99 for their second Eversense^® E3 Sensor. 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. If a patient's commercial insurance does not cover Eversense^® E3, they must provide a distributor invoice instead of an EOB. The patient must pay the first $99 of the invoice amount. The program benefit will cover the invoice amount less $99 up to the maximum allowed by the program for 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. If a patient's commercial insurance does not cover Eversense^® E3, they must provide a distributor invoice instead of an EOB. The patient must pay up to the the first $600 of the invoice amount. The program benefit will cover the invoice amount less $600 up to the maximum allowed by the program for purchase. 
• 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 May 3, 2023. 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 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