NovoPen Echo® Savings Card Program

Patient Eligibility and Restrictions:

Patient is not eligible if he/she participates in or seeks reimbursement or submits a claim for reimbursement to any federal or state healthcare program with prescription drug coverage, such as Medicaid, Medicare, Medigap, VA, DOD, TRICARE, or any similar federal or state health care program (each a Government Program), or where prohibited by law. Patient must be enrolled in and must seek reimbursement from or submit a claim for reimbursement to a commercial insurance plan. Pay as little as (“PALA”) $0 per device, subject to a maximum savings of $54 per device. Offer excludes full cash-paying patients. By using this offer, you are certifying that you meet the eligibility criteria and will comply with the terms and conditions described herein and will not seek reimbursement for any benefit received through this card. Novo Nordisk’s Eligibility and Restrictions and Offer Details may change from time to time, and for the complete and most recent version, please visit NovoCare.com. Patients with questions about the Savings Card offer may call 1-888-910-1264.

This offer is valid in the United States and may be redeemed at participating retail pharmacies. Availability of the offer in Massachusetts will be dependent upon state law in effect at the time patient presents the offer when paying for the covered medications. Void where taxed, restricted, or prohibited by law. This offer is not transferable and is limited to one offer per person. Not valid if reproduced.

Cash Discount Cards and other non-insurance plans are not valid under this offer. If the patient is eligible for drug benefits under any program other than a commercial insurance plan which covers this product, the patient cannot use this offer. This Savings Card cannot be combined with any coupon, certificate, voucher, or similar offer.

Patient is responsible for complying with any insurance carrier co-payment disclosure requirements, including disclosing any savings received from this program.

This program is managed by ConnectiveRx on behalf of Novo Nordisk. The parties reserve the right to rescind, revoke, or amend this offer without notice at any time.

Offer Details:

Pay as little as (“PALA”) $0 for one pen, subject to a maximum savings of $54 (“Savings Benefit”) per prescription fill.

Pharmacist:

When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any Government Program for this prescription, or where prohibited by law. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. By participating in this program, you are certifying that you will comply with the eligibility criteria and terms and conditions described herein. You also certify that you will not seek reimbursement for any benefit received through this card.

Pharmacist instructions for a patient with an Eligible Third Party: Submit the claim to the primary Third Party Payer first, then submit the balance due to CHANGE HEALTHCARE as a Secondary Payer COB (coordination of benefits) with patient responsibility amount and a valid Other Coverage Code (eg, 8). Where patient is Insured Not Covered, or a Prior Authorization (PA), Step Edit, or NDC Block is required by the Primary Payer, submit the balance due to CHANGE HEALTHCARE as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code 3. The patient is responsible initially for the Pay As Little As amount and the card pays up to the Savings Benefit. Offer excludes full cash-paying patients. Reimbursement will be received from CHANGE HEALTHCARE. For any questions regarding CHANGE HEALTHCARE online processing, please call the Help Desk at 1-800-433-4893.

NovoCare®, NovoPen Echo®, and PenFill® are registered trademarks of Novo Nordisk A/S.
Novo Nordisk is a registered trademark of Novo Nordisk A/S.

© 2020 Novo Nordisk  All rights reserved. US20NC00077  December 2020