*Omnipod DASH® 30-Day Free Trial
Terms and Conditions
1. Program Eligibility
Eligibility criteria: Subject to program limitations and terms and conditions, the Omnipod DASH 30-day Free Trial Program (the “Program”) is open to patients who have a valid Omnipod DASH prescription and who have commercial or private insurance, including plans available through state and federal healthcare exchanges. The Program is open only to new Pod Therapy patients coming from multiple daily injections or tubed pumps only who have not previously used Omnipod® 5, Omnipod DASH or Omnipod Insulin Management System.
This offer is not valid for participants whose Omnipod DASH prescription is paid for in whole or in part by Medicare, Medicaid, or any other federal or state programs, or where prohibited by law. Participants on certain commercial insurance plans may not be eligible. This offer is only valid in the United States, Puerto Rico, and the U.S. territories. Please contact Insulet Customer Support at 1-800-591-3455 for details.
2. Program Details
With this program, Participants may be eligible to receive a 30-day supply of Omnipod DASH products at no cost for them. Eligible participants have two (2) options, based on the following:
• A participant shall sign the 30-day Omnipod DASH Free Trial Acknowledgement through the appropriate platform providedby Insulet’s pharmacy partner.
• Once Insulet, or its pharmacy partner, has received the request, including a valid prescription for the Omnipod DASH IntroKit and Omnipod DASH Pods, the participant’s benefits will be checked by Insulet or its pharmacy partner.
• If the benefits check results in a monthly copay equal to or below two hundred dollars ($200), then Insulet, or its pharmacy partner, shall issue a one-time only copay card to the participant, for a value equal to the out-of-pocket expenses the participant would have to pay for an Omnipod DASH 30-day initial shipment, in accordance with Section 3, below.
• If the benefits check result in a copay greater than two hundred dollars ($200), Insulet, or its authorized partners, shall arrange for the shipment of one (1) Omnipod DASH Intro Kit, in accordance with Section 4, below.
• For the purpose of clarity, the term “copay” shall encompass any out-of-pocket expense for one (1) month’s supply of Pods, including any deductible, copays and other out-of-pocket expenses that the participant would have to disburse to procure said supply of Pods.
• Any copay assistance may not apply to a participant’s health plan’s deductible if prohibited by state law or by a health plan.
Insulet reserves the right to change, amend or rescind this Program, in whole or in part, at any time.
3. Copay Card
Should participant be deemed eligible to receive an Omnipod DASH Copay Card, participant shall receive electronically one (1) Omnipod DASH Copay Card, valid for a single use, in the amount required for the participant to procure a 30-day supply of Omnipod DASH Pods at a participating pharmacy. In addition, Insulet’s pharmacy partners shall ship, at no cost to participant, one (1) Omnipod DASH Starter Kit, which shall include:
• One (1) Omnipod DASH Personal Diabetes Manager (PDM)
• One (1) Omnipod DASH User Guide
• One (1) PDM charging cable
The Omnipod DASH Starter Kit shall be delivered to the shipping address indicated by participant in their Acknowledgment Form. Any estimate date of delivery is given solely for participant’s information and does not constitute a warranty that the Starter Kit will be delivered on said date. Participant is responsible to provide an accurate delivery address, to receive shipment of the Starter Kit and to verify the content of the Starter Kit.
4. Product Dispense
Should participant be deemed eligible to receive a one-time dispense of Omnipod DASH Pods at no cost to them, Insulet, or its authorized partner, shall dispense one (1) Omnipod DASH Intro Kit, which shall include:
• One (1) Omnipod DASH PDM
• Eleven (11) Omnipod DASH Pods
• One (1) Omnipod DASH User Guide
• One (1) PDM charging cable
The Omnipod DASH Intro Kit shall be delivered to the shipping address indicated by participant in their Acknowledgment Form. Any estimate date of delivery is given solely for participant’s information and does not constitute a warranty that the Intro Kit will be delivered on said date. Participant is responsible to provide an accurate delivery address, to receive shipment of the Intro Kit and to verify the content of the Intro Kit.
