MyInsulinRx™ SMS Program Terms & Conditions
Terms and conditions:
In order to redeem this offer, patient must have a valid prescription for a covered insulin. A valid Prescriber ID# is required on the prescription. Patient is not eligible where prohibited by law. This offer may not be redeemed for cash. This offer is available for uninsured patients, patients with commercial insurance, and Medicare Part D Patients who were first enrolled in 2020 and re-enrolled each subsequent calendar year. If you are commercially insured, this offer will work outside of your insurance, will not count toward any deductibles, and cannot be applied to a patient’s maximum out-of-pocket costs. No new applicants to the program who are 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), are eligible to enroll in this offer. Once enrolled in the program, the Savings Offer is valid for the calendar year. Novo Nordisk’s Eligibility and Restrictions, and Offer Details, may change from time to time without prior notice. For latest Terms and Conditions, please visit this page. Patients with questions may call 1-888-910-0632.
For any Medicare Part D patients who were enrolled in the Novo Nordisk My$99Insulin Program first in 2020 and who re-enrolled each subsequent calendar year thereafter, please note that in order to participate in 2024, you will need to re-enroll. By re-enrolling in the program, you certify that you will purchase all insulin prescriptions covered under this program before 12/31/24 by using the MyInsulinRx™ Savings Offer and will not use Medicare Part D benefits, even if your benefits change. Any re-enrollments in 2024 must be done either by following the instructions provided in a letter sent to your home in December 2023, or by calling 1-833-793-1861 to provide certain insurance and other enrollment information.
By using this offer, you are certifying that you meet the eligibility criteria and will comply with the terms and conditions described herein, that you will not seek reimbursement for any benefit received through this offer, and that you acknowledge and agree that any amounts paid in connection with this offer cannot count toward Medicare Part D True Out-of-Pocket (TrOOP) costs.
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 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 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.
By activating this offer, patient represents and warrants that he or she has not submitted, and will not submit, a claim for reimbursement to any payer or prescription insurance plan, including any government program, for this prescription. Patient is responsible for complying with any insurance carrier 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.
Eligible patients may pay $35 for a monthly supply of any combination of Novo Nordisk insulin products (up to 3 vials or 2 packs of pens). Once enrolled, the Savings Offer is valid for each month during the calendar year. Re-enrollment is required each year. This cost does not apply to any deductibles or maximum out-of-pocket costs you may have.
When you apply this offer, you are certifying that you have not submitted a claim for reimbursement to any payer or prescription insurance plan, including 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 or apply the benefit received to the True Out-of-Pocket (TrOOP).
Patient is not eligible if he/she seeks reimbursement from any payer or prescription insurance plan.
Submit each claim to SS&C Health using BIN 019158. A valid Other Coverage Code (eg, 0 or 1) is required. The patient is responsible for the first $35 per 35 mL of any combination of covered insulins and reimbursement will be received from SS&C Health.
Patient will pay $35 per 35 mL (ie, up to 3 vials or 2 packs of pens or any combination thereof) up to a maximum of 150 mL per calendar month. Once enrolled in the program, the Savings Offer is valid for the calendar year.
For any questions regarding SS&C Health online processing, please call the Pharmacy Help Desk at 1-844-373-0987.
Last Updated 9/13/23 (effective date)