Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. 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.
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). 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). Pharmacist Instructions: Submit claim to primary Third Party first. 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.
patients who reside in New Mexico 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. 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. Maximum benefit for receiver, transmitter, and sensor kit is $140. Patients may also be eligible for an instant rebate of up to $20 off on one sensor 3-pack if initial copay exceeds $60. Eligible patients may use this voucher to obtain an instant rebate of up to $60 off one receiver and one transmitter. 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. Patient Category 1: Cost-Sharing Assistance for Covered CGM: U.S.
Patients with questions about the Dexcom instant rebate offer should call 1-84. 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. 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. If so, ConnectiveRx will administer an instant rebate on limited supplies of Dexcom G6 products. If your pharmacy is participating in this program, ConnectiveRx will help the pharmacy confirm that you meet the eligibility criteria. Present this card to the pharmacist when you pick up your Dexcom G6 prescription.
PLUS the additional program-specific criteria described in one of the sections below.
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.
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.