Eligibility and restrictions for Novo Nordisk savings card 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 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. 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.  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 most recent version, please visit this wegpage. Re-confirmation of information may be requested periodically to ensure accuracy of data and compliance with terms. Patients with questions about the Savings Card may call 1-844-590-0570.

This offer is valid in the United States 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 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. 

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 $0 per fill, subject to a maximum savings of $12,000 per calendar year. 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, and Esperoct® [antihemophilic factor (recombinant), glycopegylated-exei].

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 (e.g., 8). The patient is responsible initially for the PALA amount and the card pays up to the Savings Benefit. Reimbursement will be received from CHANGE HEALTHCARE.

Provider Instructions:  

Submit the claim and completed copay expenditure form to ConnectiveRx Claims Processing Center.  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. For any questions regarding reimbursement processing, please call customer service at 844-590-0570.  

Esperoct®, Novoeight®, NovoSeven®, Rebinyn®, and Tretten® are registered trademarks and NovoSecure™ is a trademark of Novo Nordisk Health Care AG.
NovoCare® is a registered trademark of Novo Nordisk A/S.
Novo Nordisk is a registered trademark of Novo Nordisk A/S.
All other trademarks, registered or unregistered, are the property of their respective owners.
© 2021 Novo Nordisk  All rights reserved. US21HRBD00126  August 2021