Essurance Promise Program Details
Once both Essure inserts are placed and the Essure (HSG) Confirmation Test results are read, if a patient is told she cannot yet rely on Essure for birth control for ANY reason, Conceptus, Inc. will pay her out-of-pocket costs for the test, up to $150 per test, according to the following conditions:
- The Essure patient must register for the Essurance Promise Program online at www.essurancepromise.com or by phone through the Essurance Promise Program Information Center at 855-323-7873 within 30 days of her Essure procedure.
- The Essurance Promise Program is valid for nine months from the date of the Essure procedure.
- To make a claim, the Essure patient must send a copy of her medical bills for the HSG test, along with her HSG report, to the Essurance Promise Program Information Center at Essurance Promise Program, PO Box 2605, Appleton, WI 54912. You can also email them to EssurancePromise@essure.com or fax them to 877-496-0003.
- Within 30 days of receipt of all of the above documentation, Conceptus will issue payment of up to $150 per HSG test.
- If additional inserts are placed due to expulsion or for ANY other reason, the eligibility period resets and the Essurance Promise Program extends for an additional nine months.
- If, according to the HSG report, the Essure inserts are visibly in their proper place yet the Essure patient's tubes are not occluded, the patient must continue to use alternative birth control methods and return for another HSG test in three months. Note: In clinical trials, all women who had properly placed inserts and returned for an additional HSG test were found to have their tubes blocked and were able to rely on Essure for permanent birth control.
- Federal law prohibits Conceptus from offering the Essurance Promise Program to patients who are covered by Medicaid or Medicare.
|
