Passport for Pumpers



You can participate in this promotion by providing the required information and submitting this entry form. You agree that it will be governed by our site’s Privacy Policy. You do not need to provide the optional information to participate; however, the additional information we collect will help us provide you with information, products and services that better meet your needs and interests. Be sure to read the restrictions governing this promotion before entering.


*Fields with an asterisk are required.
1. Your Passport for Pumper card information


2. Your contact information



Example: xxx-xxx-xxxx
 

 
 


  


 

What is your relationship to the person with diabetes?  

Please answer the above question.

Change

5. What methods do you use to manage your diabetes?

Who is the manufacturer of your insulin pump?  



Restrictions: Maximum 6 uses per person for a maximum benefit of 6 months of therapy. Minimum $5 patient out-of-pocket expense per month of therapy, with a maximum coverage of UP TO $45 per month of therapy. Not available for individuals enrolled in Medicare, Medicaid, TRICARE, or any other federal or state healthcare plan. Not valid in MA for patients covered by private insurance. May not be accepted at all pharmacies. Co-pay rebate is valid for 6 months therapy. Void where prohibited or restricted by law. LifeScan, Inc. reserves the right to rescind, revoke, or amend this offer without notice at any time.
†OneTouch® Ultra® Blue Test Strips at a $5 co-pay per month of therapy, with up to $45 in reimbursement per month of therapy, for up to 6 months of therapy per patient.

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