Diabetes Savings Card Program

Novo Nordisk Savings Card

Eligibility and Restrictions:

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 webpage. 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 1-877-304-6855.

This offer is valid in the United States and may be redeemed at participating retail pharmacies. Absent a change in Massachusetts law, effective July 1, 2019, the Savings Card will no longer be valid for residents of Massachusetts. 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:
This offer is good for eligible patients purchasing up to a 90-day supply.

(a) LEVEMIR®, NOVOLOG®, NOVOLOG® MIX 70/30 or VICTOZA®: Pay as little as (“PALA”) $25 per 30-day, $50 per 60-day, or $75 per 90-day supply for the first brand for up to 24 months from the date of Savings Card activation, subject to a maximum savings of $100 per 30-day (“Savings Benefit”), $200 per 60-day, or $300 per 90-day supply. PALA $20 per 30-day, $40 per 60-day, or $60 per 90-day supply for the second brand for up to 24 months from the date of Savings Card activation, subject to a maximum savings of $100 per 30-day (“Savings Benefit”), $200 per 60-day, or $300 per 90-day supply. The second brand must be filled within 30 days of the fill date of the first brand.

(b) TRESIBA®: Pay as little as (“PALA”) $15 per 30-day, $30 per 60-day, or $45 per 90-day supply for up to 24 months from the date of Savings Card activation, subject to a maximum savings of $500 per 30-day, $1,000 per 60-day, or $1,500 per 90-day supply.

(c) XULTOPHY®: Pay as little as (“PALA”) $30 per 30-day, $60 per 60-day, or $90 per 90-day supply for up to 24 months from the date of Savings Card activation, subject to a maximum savings of $400 per 30-day supply, $800 per 60-day, or $1,200 per 90-day supply.

Get one (1) free box of Novo Nordisk needles when you activate your Savings Card and enroll in the program. Limit 1 box of needles per person and maximum savings of $60. Needles are sold separately, will need a prescription and need to be processed by a pharmacist. Needles must not be shared.

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. 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.