TERMS AND CONDITIONS
Dexcom is partnering with a pharmacy claims administrator, ConnectiveRx, to offer a limited-time trial program for patients in select areas who fill their G6 prescriptions at participating pharmacies and who either (1) have commercial health insurance coverage for Dexcom G6 CGM products but desire financial support with their out-of-pocket cost-sharing amounts or (2) have commercial health insurance that does not cover their Dexcom G6 CGM products. Patients who obtain Dexcom G6 products through this program are prohibited from selling such products or attempting to claim reimbursement for the price of the products from any other party.
In order to redeem this offer, you must meet all of the following criteria: plus additional program-specific criteria described in one of the sections below.
• have a valid prescription for a Dexcom G6 CGM,
• be enrolled in a commercial health insurance plan, and
• not receive benefits under any government-funded health care program, and
• not be eligible for coverage of Decom G6 products from your health insurer.
PLUS the additional program-specific criteria described in one of the sections below.
Present this card to the pharmacist when you pick up your Dexcom G6 prescription. If your pharmacy is participating in this program, ConnectiveRx will help the pharmacy confirm that you meet the eligibility criteria. If so, ConnectiveRx will administer an instant rebate on limited supplies of Dexcom G6 products. This offer may not be redeemed for cash. By using this offer, you are certifying that you meet the eligibility criteria and will comply with the terms and conditions described in the Eligibility and Restrictions section below. By using this offer, you also acknowledge and agree that Dexcom and ConnectiveRx may modify these Terms and Conditions at any time without notice to you. Patients with questions about the Dexcom instant rebate offer should call 1-844-247-2080.
Patient Category 1: Cost-Sharing Assistance for Covered CGM: U.S. patients who reside in the U.S., but not in Massachusetts, and whose commercial health insurance covers Dexcom G6 CGM as a prescription benefit, may use this program to receive assistance with cost-sharing amounts that they would otherwise pay out of pocket at the pharmacy. Eligible patients may use this voucher to obtain an instant rebate of up to $60 off one receiver and one transmitter. Patients may also be eligible for an instant rebate of up to $20 off on one sensor 3-pack if initial copay exceeds $60. Maximum benefit for receiver, transmitter, and sensor kit is $140.
Patient Category 2: Assistance for Select Patients with Coverage Restrictions: Some commercial health care plans’ pharmacy benefits pay for Dexcom’s G6 continuous glucose monitoring devices and supplies, however, some plans do not cover CGM for some or all patients even if their doctors consider it medically necessary. U.S. patients who reside in New Mexico or West Virginia, and whose commercial health insurance does not cover Dexcom G6 CGM may use this program to obtain up to one (1) Dexcom G6 receiver at an out-of-pocket cost to the patient of $10; up to four (4) Dexcom G6 transmitters at an out-of-pocket cost to the patient of $70 per transmitter; and up to twelve (12) packs of three (3) Dexcom G6 sensors each at an out-of-pocket cost to the patient of $70 per 3-pack. If at any time you become enrolled in an insurance plan that covers Dexcom G6 CGM, you will no longer be eligible for this discount and must call the ConnectiveRx line listed above.
Pharmacist Instructions: Submit claim to primary Third Party first. If primary Third Party covers, then submit balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amounts specified above under “Patient Category 1” and valid Other Coverage Code (OCC08). If all applicable Third Parties decline coverage, then charge patient out-of-pocket amounts specified above for “Patient Category 2” and submit balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and valid Other Coverage Code (OCC03). When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental programs for this prescription. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. By participating in this program, you are certifying that you will comply with the terms and conditions described in the Eligibility and Restrictions section below. For any questions regarding Change Healthcare processing, please call the Help Desk at 1-800-422-5604.
Eligibility and Restrictions (all programs): Valid for commercially insured patients age 2 years and older only. According to federal and state laws, this offer is not valid for beneficiaries of Medicaid, Medicare, Tricare or other federal or state health programs (such as medical assistance programs). If the patient is eligible for drug benefits under any such program, the patient cannot use this offer. By using this offer, the patient certifies that he or she will comply with any terms of his or her health insurance contract requiring notification to his or her payer of the existence and/or value of this offer. This promotion is not transferable and cannot be combined with any other programs, offers or discounts. Not valid if reproduced. Void where prohibited by law. Program managed by ConnectiveRx on behalf of Dexcom. The parties reserve the right to rescind, revoke or amend this offer without notice at any time.
This card must be activated before fill and presented at the time of prescription fill for instant savings. Must be activated or used by December 31, 2021.
Patients with questions about the Dexcom instant rebate offers should call 1-844-247-2080.
Additional Terms: Category 1: Cost-Sharing for Covered CGM
Valid for patients with pharmacy coverage for Dexcom G6 products only. Limit 1 offer per purchase. This offer is not valid in Massachusetts or U.S. insular areas.
Additional Terms: Category 2: Assistance for Select Patients with Coverage Restrictions
Valid for patients with no coverage for Dexcom G6 products only. Limit 1 offer per 12 months. This offer is only valid in New Mexico and West Virginia.
BRIEF SAFETY STATEMENT
Indications for Use
The Dexcom G6 Continuous Glucose Monitoring System (G6) is an autonomous, real-time, continuous glucose monitoring device indicated for the management of diabetes in persons age 2 years and older. The glucose measurements are intended to replace fingerstick blood glucose testing for diabetes treatment decisions and behavioral modifications. The G6 can communicate wirelessly to and from other interoperable devices.
Do not wear your G6 (sensor, transmitter, receiver, or smart device) for magnetic resonance imaging (MRI), computed tomography (CT) scan, or high-frequency electrical heat (diathermy) treatment. It is MR Unsafe.
Failure to use the Dexcom G6 Continuous Glucose Monitoring System (G6) and its components according to the instructions for use provided with your device and available at https://www.dexcom.com/safety-information and to properly consider all indications, contraindications, warnings, precautions, and cautions in those instructions for use may result in you missing a severe hypoglycemia (low blood glucose) or hyperglycemia (high blood glucose) occurrence and/or making a treatment decision that may result in injury. If your glucose alerts and readings from the G6 do not match symptoms or expectations or you’re taking over the recommended maximum dosage amount of 1000mg of acetaminophen every 6 hours, use a blood glucose meter to make diabetes treatment decisions. Seek medical advice and attention when appropriate, including for any medical emergency.