Eversense PASS Programs Terms and Conditions

Experience the EVERSENSE^® 365 CGM system at an affordable price with the Eversense PASS^® Program. The Eversense PASS Program provides eligible patients with financial assistance for the Eversense 365 System, but not for procedures to insert and/or remove the system.

Eligibility – To be eligible, the patient must have a commercial insurance plan with or without coverage for the EVERSENSE^® 365 CGM. The patient must also meet medical coverage criteria for CGM as indicated by their insurance provider. There is a maximum benefit payout of $2,500 for patients who may have a responsibility to pay more than the offered amount. The Eversense PASS Program offers a maximum benefit payout, and therefore some patients may have a responsibility to pay more than the offered amount. Patients should have a benefits investigation completed by the healthcare provider or company from whom they are purchasing the device to obtain an estimate of the expected out of pocket. This Eversense PASS Program offer will not apply to the Eversense E3^® CGM System.

Exclusions – Government insurance as primary, secondary, or other coverage (i.e., Medicare, Medicare Advantage, Medicaid, and TRICARE).

The offers only apply to the cost of the product (sensor and transmitter). It does not cover the cost of the insertion and removal procedure. Limitations and Restrictions may apply. Ascensia Diabetes Care and Senseonics, Incorporated reserve the right to change or terminate these programs at any time without notice.

Terms and Conditions – Eversense PASS^® Program for Eversense 365

• The Eversense PASS^® (Payment Assistance and Simple Savings) (the “Eversense PASS Program”) is offered by Ascensia Diabetes Care US, Inc. (“Ascensia”) or Senseonics, Incorporated (“Senseonics”) to eligible patients who have a valid prescription for the Eversense^® 365 Continuous Glucose Monitoring System and may need financial assistance with out-of-pocket costs. The Eversense PASS Program is limited to patients who meet the eligibility requirements set forth herein.
• Patient must request financial assistance for (i) the Eversense^® 365 Sensor, and accompanying Eversense^® 365 Smart Transmitter (the Eversense^® 365 Sensor and the Eversense^® 365 Transmitter, collectively referred to as the “Eversense^® 365 Products”).
• Patient must have a valid prescription for the Eversense^® 365 products (sensor and transmitter) for an FDA-approved indication.
• Patient must be 18 years or older.
• The Eversense PASS Program is not valid for patients enrolled in : (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 Eversense PASS Program is also not available where prohibited by law or by the patient’s health plan or insurance company.
• 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^® 365 Products. The benefits available under the Eversense PASS Program are valid for the patient’s out-of-pocket cost for the Eversense^® 365 Products only. They are 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^® 365 Products.
• The Eversense PASS Program consists of two separate programs, the DME Program & Bundled Payment Program, and are available based upon the purchase requirements by the patient’s commercial insurance provider.

• DME Program -

• The Eversense PASS^®DME Program (“DME Program”) only applies if the Eversense^® 365 Products are billed to the patient’s health plan(s) under a separate billing code from any procedures associated with the insertion and/or removal of the Eversense^® 365 Products. The DME Program does not apply in situations where the patient has a benefit plan under which Eversense^® 365 Products are to be billed together with insertion and/or removal procedures under a combined or global billing code based on health plan billing procedures. 
• Patient Responsibilities: Patient must pay up to $199 for their Eversense^® 365 Sensor and Transmitter. The benefit available under the DME Program is limited to the patient’s financial obligation to pay for the Eversense^® 365 Products (as indicated on the Explanation of Benefits (EOB)) less $199, subject to the maximum allowed (cap) by the DME Program per purchase. The patient must pay the first $199 of the patient out-of-pocket amount for each purchase of Eversense^® 365 Products that qualifies for the DME Program. The maximum benefit under the DME Program per purchase transaction is $2,500.
• Patient agrees to seek reimbursement for the Eversense^® 365 Products from patient’s commercial health plan(s). Patient agrees not to seek reimbursement for all or any part of the Eversense^® 365 Products from any third party, or Government Program.
• Patient agrees to and is responsible for reporting receipt of DME 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 DME Program, as may be required. This offer may not be redeemed for cash or anything else of value.

• Bundled Payment Program - 

• The Eversense PASS^® Bundled Payment Program (the “Bundled Payment Program”) only applies if  the Eversense^® 365 Products are billed together with insertion and/or removal procedures under a combined or bundled billing code based on the billing procedures of the patient’s commercial health plan(s).
• Patient Responsibilities: For each claim to the Bundled Payment Program, the patient must sign a Patient Enrollment Form agreeing to the program terms and conditions. Patient must pay up to $199 for their Eversense^® 365 Sensor and Transmitter. The benefit available under the Bundled Payment Program is limited to 90% of the patient financial responsibility as indicated on the applicable Explanation of Benefits (EOB) less $199, capped at the maximum allowed benefit under the Bundled Payment Program. The current maximum allowed benefit is $2,500.
• Patient’s Health Care Provider (“HCP”) must enroll in the Bundled Payment Program and agree to seek reimbursement for the Eversense^® 365 from each patient’s commercial health plan(s). HCP must agree not to seek reimbursement for all or any part of the Eversense^® 365 from any Government Program. HCP must agree not to accept reimbursements or payment for the Eversense^® 365 that in total exceed 100% of the allowed amount identified by the patient’s commercial health plan company on the EOB. Patient shall assign their benefits under the Bundled Payment Program to the Patient’s HCP, with any applicable program payments paid to the enrolled HCP.
• Patient agrees to and is responsible for reporting receipt of Bundled Payment 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 Bundled Payment Program, as may be required. The Bundled Payment Program benefit may not be redeemed for cash or anything else of value.

• The DME Program and Bundled Payment Program do not represent or constitute insurance of any kind. The monetary assistance under the programs are non-transferable, limited for each eligible patient, and may not be combined with any other offer.
• The programs benefits cannot be combined with any other assistance program, free trial, discount, prescription savings card, or other offer.
• Patients must consent to their personal and health data being received, accessed, and/or shared by and between Ascensia and/or Senseonics and any contracted Eversense PASS Program partners, solely for purposes of operating the Eversense PASS Program for the patient (which may include assistance in (i) obtaining Eversense^® 365 Products, and (ii) health plan coverage determinations through benefit verification, pre-authorization and/or appeal submissions).
• By enrolling in the Eversense PASS Program, Patient will authorize Ascensia and Senseonics to: (i) use and disclose Patient’s health-related information, including but not limited to insurance details and diabetes status, related to the Eversense^® 365, adhesive patches and/or the Eversense insertion tool, as well as health records and insurance information; and ii) share this information with any third-party service providers and authorized agents as necessary to arrange for the furnishing of the Eversense^® 365, including but not limited to obtaining insurance coverage, payment information and assistance, and reimbursement information for the Eversense^® 365. Patient will consent to Ascensia and Senseonics and/or its contracted partner(s) contacting Patient by phone, email, or text to obtain and provide reimbursement and payment information, discuss available products and services, and gather relevant information related to the Eversense PASS Program. Patient will acknowledge that Patient understands that neither Ascensia nor Senseonics will charge for any texting services, but standard message and data rates may still apply. In carrying out these activities, Ascensia and/or Senseonics and/or their authorized third party service providers may relay information to health insurer(s), receive information from health insurer(s), and communicate such information to Patient’s healthcare provider, to administer the Eversense PASS Program. Patient acknowledges and understands that this authorization is voluntary and that Patient may revoke this authorization at any time. Information that has already been disclosed may be further disclosed once the authorization has been revoked. Patient acknowledges and understands that if Patient chooses to revoke this authorization, Patient must do so in writing to the following e-mail address EversensePS@ascensia.com or by calling customer service at 1-844-736-7348 available from 8:00 AM to 12:00 AM EDT Monday to Sunday. This authorization will remain in effect until revoked by Patient or until the end of Patient’s participation in the Eversense PASS Program.
• Ascensia and Senseonics (either directly or through a contracted Eversense PASS Program partner) reserve the right to rescind, revoke, or amend this Eversense PASS Program without notice at any time. The Eversense PASS Program is void where prohibited; rules and restrictions apply.