Eligibility and restrictions for Novo Nordisk savings offer program
In order to redeem this offer, patient must have a valid prescription for the brand being filled. A valid Prescriber ID# is required on the prescription. Patient is not eligible if he/she is enrolled in any federal or state health care 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 seeks reimbursement under such a Government Program, or where prohibited by law. Patient must be enrolled in a commercial insurance plan. The brand and the prescription being filled must be covered by the patient’s commercial insurance plan. Offer excludes full cash-paying patients. This offer may not be redeemed for cash. This offer is not valid when the entire cost of your prescription drug is eligible to be reimbursed by a commercial insurance plan or other commercial health or pharmacy benefit programs. 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. Novo Nordisk’s Eligibility and Restrictions, and Offer Details, may change from time to time, and for the most recent version, please visit this webpage. Reconfirmation of information may be requested periodically to ensure accuracy of data and compliance with terms. Patients with questions about the Savings Offer may call 1‑844‑590‑0570.
This offer is valid only in the United States, and its territories, unless prohibited by law and may be redeemed at participating retail pharmacies. Availability of the Savings Offer in Massachusetts will be dependent upon state law in effect at the time patient presents the Savings 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 noninsurance 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 offer cannot be combined with any coupon, certificate, voucher, or similar offer.
Patient is responsible for complying with any insurance carrier copayment disclosure requirements, including disclosing any savings received from this program. It is illegal to (or offer to) sell, purchase, or trade this offer.
This program is not health insurance. 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: Effective as of January 2, 2024 (“Effective Date”), commercially insured patients with product coverage under their insurer’s pharmacy or medical benefit, including those within their deductible phase, may pay as little as $0 per fill, subject to a maximum savings on the patient’s out-of-pocket drug costs of up to $15,000 per calendar year. After reaching the maximum program benefit, the patient will be responsible for all remaining out-of-pocket expenses. The products covered under this program include NovoSeven® RT (coagulation Factor VIIa, recombinant), Novoeight® (antihemophilic factor, recombinant), Tretten® (Coagulation Factor XIII A-Subunit [Recombinant]), Rebinyn® Coagulation Factor IX (Recombinant), GlycoPEGylated, Esperoct® [antihemophilic factor (recombinant), glycopegylated-exei]. This Savings Offer is valid for 48 months from the date of enrollment and the annual maximum savings of $15,000 will reset every January 1st until program expiration.
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.
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 SS&C Health as a Secondary Payer using BIN 019158 with patient responsibility amount and a valid Other Coverage Code (eg, 8). The patient is responsible initially for the PALA amount and the offer pays up to the Savings Benefit. Reimbursement will be received from SS&C Health. For any questions regarding SS&C online processing, please call the Help Desk at 1-844-373-0987.
Provider instructions for medical claims:
To request reimbursement for medical claims, providers can request a copay expenditure form and instructions by calling the ConnectiveRx Claims Processing Center at 1‑844‑590‑0570. Participation in this program must comply with all applicable laws and regulations as a 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. Reimbursement will be received from ConnectiveRx.
Please send the completed form and all required documentation to the following address and/or fax number:
Copay Assistance Program
C/O ConnectiveRx Claims Processing Center
P.O. Box 2355, Morristown, NJ 07962
FAX: 1-908-809-6239
If you have any questions regarding the Copay Expenditure Form or the copay process for Novo Nordisk's medicines administered to a commercially insured patient under their insurance plans medical benefit, please contact Copay Assistance Program at 1‑844‑590‑0570.