More than a script Bulk Order

More Than A Script - Stelo Bulk Order Form
Source
Pharmacy Name*
Pharmacist Contact Information*

First NameLast Name
Pharmacy NPI*
Please provide the email and phone number you'd like us to use for order-related communication.
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Attach W-9 here or email it to provider-bulk-orders@stelo.com Business name/clinic name must match on all documents. W-9 is required to complete order.

Cancelof
Ship To Information

Please note, we can't ship to PO Boxes
Name*

First NameLast Name
ATTN*
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
If shipping address is the same as billing address, click yes.

YesNo
Bill To Information
Name*

First NameLast Name
ATTN*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Quantity

1 case contains 24 Stelo units. 1 Stelo unit contains 2 biosensors. Single sensors not for sale
Quantity*

2 Cases (48 units, 96 biosensors) $3,3603 Cases (72 units, 144 biosensors) $5,0404 Cases (96 units, 192 biosensors) $6,7205 Cases (120 units, 240 biosensors) $8,400
Payment Method*

Credit CardCheck / ECheck / ACH
Please note that shipping and handling are included in the total price, but taxes (as applicable) are not. Orders are payable by credit card and check only, and will ship after payment has been processed. A final order total will be provided, including any applicable taxes, prior to payment processing.
Payment Information
Full payment, including applicable taxes, must be received before the product can be shipped.

Credit Card: A member of the Stelo team will contact you directly to securely collect your credit card information.
Check: You will receive a detailed payment quote to process your order.
Contact Person for Payment*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Best time of day to call
Email*
example@example.com
We’re excited to welcome your pharmacy to the BCBS North Carolina More Than a Script (MTS) program featuring Stelo, Dexcom’s over-the-counter continuous glucose monitor (CGM) for non-insulin patients.

By digitally signing and submitting this form, you agree to the terms and conditions and labeling guidelines outlined below.

Customer Acknowledgment Requirement

Before providing or reselling Stelo to an end user, you must ensure the customer acknowledges that the products are NOT intended for use by individuals who are:
- On insulin
- On dialysis
- Experiencing problematic hypoglycemia
- Under 18 years of age
Stelo must be kept behind the counter and is not to be resold. It is exclusively available to enrolled MTS members. BCBS NC will reconcile claims against inventory to ensure program integrity.

Before submitting, please review the entire Terms and Conditions, Minimum Advertised Price (MAP) Policy and Indications For Use/Contraindications/Warnings provided in the dropdowns below. A copy will also be sent to you via email after submission.

Purchase Order Terms and Conditions

Stelo MAP Policy

Indications For Use/Contraindications/Warnings
Read the following:

Indications for Use:
The Stelo Glucose Biosensor System is an over-the-counter (OTC) integrated Continuous Glucose Monitor (iCGM) intended to continuously measure, record, analyze, and display glucose values in people 18 years and older NOT on insulin. The Stelo Glucose Biosensor System helps to detect normal (euglycemic) and low or high (dysglycemic) glucose levels. The Stelo Glucose Biosensor System may also help the user better understand how lifestyle and behavior modification, including diet and exercise, impact glucose excursion. The user is not intended to take medical action based on the device output without consultation with a qualified healthcare professional.

Contraindications:
No MRI/CT/diathermy – MR unsafe.

Warnings:
i. This device has a choking hazard.
ii. Don't use if you have problematic hypoglycemia.
iii. Don't use if you are on dialysis.
iv. Don't ignore low/high symptoms and don’t change medications; consult your healthcare provider.

Visit www.stelo.com for the safety information

Sign and Submit
Signature*

Clear
The signer represents and warrants that they are duly authorized to bind the company identified in the ‘Pharmacy Name’ section above to the terms and conditions set forth herein.
Date*

MonthDayYear
Date
I acknowledge
Order Processing & Shipping

Order processing may take up to three (3) business days or longer once payment has cleared. Please allow additional time for shipping. Tracking information will be emailed once your order has shipped.
Should be Empty:

More Than A Script - Stelo Bulk Order Form

Ship To Information

Bill To Information

Quantity

Payment InformationFull payment, including applicable taxes, must be received before the product can be shipped.

Payment Information
Full payment, including applicable taxes, must be received before the product can be shipped.