START & SEE Program terms and conditions:

Eligibility and Restrictions:

• In order to redeem this offer patient must have a valid prescription for the brand being filled and must be 18 years of age or older. A valid Prescriber ID# is required on the prescription.
• 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. Tresiba Offer Eligibility: the patient must be enrolled in a commercial insurance plan and the brand must be covered by the patient’s commercial insurance plan. Freestyle Libre Eligibility: Commercially insured and cash-paying patients are eligible. This offer may not be redeemed for cash. 
• 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 offer. Eligibility and Restrictions and Offer Details may change from time to time without notice to you.
• Re-confirmation of information may be requested periodically to ensure accuracy of data and compliance with terms. Patients with questions about the Savings Card offer may call 1-877-831-0296.
• This offer is valid in the United States (excluding Massachusetts, Puerto Rico and US Territories) and may be redeemed at participating retail pharmacies.
• 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 as primary insurance under this offer. If the patient is eligible for drug benefits under any such program, 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. It is illegal to (or offer to) sell, purchase, or trade this offer. 
• Other than as required by this program, selling the FreeStyle Libre 14 day sensor, or submitting the sensor, or any services associated with them (such as sensor placement and patient training), to any third party for reimbursement, is prohibited.
• 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 $5 for a 30-day supply of Tresiba^® for up to 24 months (maximum savings of $150 per 30-day supply), and up to two (2) FreeStyle Libre 14 day sensors, provided that the patient has a valid prescription for the FreeStyle Libre system sensor. The two (2) FreeStyle Libra 14 day sensors must be redeemed within the same pharmacy claim (ie, transaction).

Eligible patients are automatically transitioned to the Novo Nordisk Diabetes Savings Card Program for Tresiba^® only once the $5 copay offer is used and a second use is attempted. For the Eligibility and Restrictions and Offer Details for the Novo Nordisk Diabetes Savings Card Program, please visit novocare.com/eligibility/savings-card.html. This offer expires 12/31/20.

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 offer.

Tresiba^® Offer 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, (e.g. 8).
• The patient is responsible for the initial $5, and the card pays up to the next $150. Reimbursement will be received from CHANGE HEALTHCARE.
• Offer excludes full cash-paying patients.
• For any questions regarding CHANGE HEALTHCARE online processing, please call the Help Desk at 1-800-433-4893.

Freestyle Libre Offer 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, (e.g. 8).
• Where patient is Insured Not Covered, or a 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 pay amount submitted will be reduced to $0 and 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.

Reference to Terms & Conditions

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). Patient must be enrolled in a commercial insurance plan. Please see reverse of card for complete terms and conditions. For Novo Nordisk Diabetes savings card terms and conditions including offer structure for continued Tresiba^® savings for eligible patients please visit novocare.com/eligibility/savings-card.html.