The Omnipod® Financial Assistance Program

1. Program Eligibility

Eligibility criteria: Subject to program limitations and terms and conditions, the Omnipod Financial Assistance Program (the “Program”) is open to patients who have a valid Omnipod DASH® or Omnipod® 5 prescription who demonstrate a financial need for assistance based on criteria established by Insulet, and who fill their prescription through the Pharmacy channel.

This offer is not valid for participants whose prescription is paid for in whole or in part by Medicare, Medicaid, or any other federal or state program. This offer is only valid in the United States, Puerto Rico, and the U.S. territories. Participants receiving their products through the Durable Medical Equipment or Pharmacy Durable Medical Equipment channel are not eligible to participate in the copay card program. Participants on certain commercial insurance plans may not be eligible. Please contact Insulet Customer Support at 1-800-591-3455 for details.
 

2. Program Details

With the Program, an approved participant who meets eligibility criteria may receive a copay card to reduce their monthly out-of-pocket expenses when filling their Omnipod® prescription. The program is described as follows:

• A program benefit that covers the participant’s eligible out-of-pocket prescription costs for Omnipod DASH and Omnipod 5 Pods (copay, deductible, or co-insurance) on behalf of the participant, in accordance with criteria determined by Insulet.
• In order to participate in the Program, a person shall complete Insulet’s Financial Assistance Program Application Form, as provided by Insulet and as may be updated from time to time.
• The form shall be filled out with true and correct information by the applicant and provided to Insulet.
• In addition, the applicant shall provide evidence of income, as directed by Insulet.
• Insulet shall evaluate the application in accordance with its policies and make a determination as to the eligibility of the applicant.
• If the application is accepted by Insulet, Insulet shall communicate to the participant the level of assistance that they will receive as part of the Program.
• The assistance shall be provided through a copay card delivered electronically by Insulet to Participant.
• The copay card shall be valid for one (1) year and covers a thirty (30) days’ fill of Pods, every month.
• Participants are solely responsible for updating Insulet with changes to their prescription, financial situation or health insurance, including but not limited to, initiation of insurance provided by the government, in addition to any change in coverage terms or other offers such as accumulator adjustment benefit design or copay maximization programs. Participants shall further inform Insulet of any change or lapse in coverage for their Omnipod ® prescription.
• Participants are responsible to provide Insulet with accurate information on their copay.

Insulet reserves the right to change, amend or rescind this Program, in whole or in part, at any time.
 

3. Limitations

The Program may not be combined with any other offer, rebate or coupon. If at any point a participant begins receiving coverage under any state or government program, the participant will no longer be able to use this card and they must contact Insulet Customer care at 1-800-591-3455 to stop their participation. Participant shall also update Insulet if their financial situation changes in a way that would make them non-eligible to participate in the Financial Assistance Program. Participating in this Program means that you are ensuring you comply with any required disclosure regarding your participation in the Program. Other restrictions may apply. Health plans, specialty pharmacies and Pharmacy Benefits Managers not specifically authorized by Insulet are prohibited from enrolling participants in the Program. The copay card shall last for a maximum of twelve (12) months per participant.

This Program is not health insurance. Insulet reserves the right to rescind, revoke or amend this offer, as well as any eligibility criterion without further notice.