NEW AFFORDABILITY
OPTIONS ON YOUR
DEXCOM G6® CGM SYSTEM

QUALIFYING PATIENTS MAY
SAVE UP TO $140 ON
DEXCOM G6®

Restrictions Apply.
Please see below for Terms
and Conditions.

Smart devices sold separately.

FILL OUT THE FORM BELOW TO SEE IF YOU ARE ELIGIBLE FOR THIS OFFER. SEE BELOW FOR TERMS AND CONDITIONS. CERTAIN RESTRICTIONS APPLY.

*Eligibility Requirements: The savings programs are offered to commercially insured patients age 2 years and older ONLY. Certain options may only be available for patients residing in New Mexico and West Virginia whose health care conditions do not qualify them for continuous glucose monitoring system (“CGM”) coverage under their commercial health insurance. These programs are NOT open to beneficiaries or enrollees of any federal-, state-, or government-funded healthcare program, such as Medicare, Medicare Advantage, Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), the Department of Defense (DoD), or Tricare®, or where prohibited by law. The questions below are not a complete eligibility screening; you should review the terms and conditions carefully to confirm that you meet the requirements for participation in one of these programs.

! If you have no insurance, or if you are covered by Medicare, Medicaid or any other state- or federally-funded benefit program, you are ineligible for this program.

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! Only patients who reside in the United States or Puerto Rico can participate in this program.
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Dexcom and ConnectiveRx do not charge for this texting service, however your carrier’s message and data rates may apply. Message frequency depends on your account. If you no longer wish to receive text messages from ConnectiveRx, text STOP to 26729. If you need more information from ConnectiveRx, text HELP to 26729.

REQUIRED INFORMATION *
First Name is a required field.
Last Name is a required field.
Date Of Birth is a required field.
Address is a required field.
City is a required field.
State is a required field.
Zip is a required field.
E-mail is a required field.
Mobile number is a required field.

By checking this box, I agree that I am eligible to participate in the program and agree to the Dexcom Voucher Program Terms and Conditions listed below. I further certify to Dexcom that I am not a beneficiary or enrollee of any federal-, state-, or government-funded healthcare program, such as Medicaid, Medicare or other federal or state healthcare programs, or a resident of Massachusetts or U.S. insular areas.

! Please accept our Terms and Conditions.

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