RYBELSUS® (semaglutide) tablets 7 mg or 14 mg Eligibility

Eligibility and Restrictions:

In order to redeem this offer patient must be 18 years of age or older and 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 a 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. Re-confirmation of information may be requested periodically to ensure accuracy of data and compliance with terms. Patients with questions about the offer may call 1-888-964-1958. This offer is valid in the United States and may be redeemed at participating retail pharmacies. Absent a change in Massachusetts law, effective January 1, 2020, the Voucher 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 Voucher 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 valid only after enrollment and activation.

If your commercial insurance plan does not cover RYBELSUS®, use of this offer permits your healthcare provider or pharmacy to share limited information with ConnectiveRx and CoverMyMeds to act on your behalf to initiate any paperwork or processes that may be necessary so that you may continue to have access to therapy.

Offer Details:

If you activated your card on, or prior to, January 31, 2020, and have a group number of EC20024001 or EC20024003:

  • Pay $10 for up to twelve, 30-day fills of RYBELSUS® through February 28, 2021. After the patient’s twelfth fill, or on March 1, 2021, whichever comes first (the “transition date”), patients with commercial drug coverage for RYBELSUS® will then pay as little as (“PALA”) $10 per 30-day supply, $20 per 60-day supply, or $30 per 90-day supply for up to 24 months from the activation date, subject to a maximum savings of $250 per a 30-day supply, $500 per 60-day supply or $750 per 90-day supply.

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, (eg 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 pays $10 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. 

Novocare® and RYBELSUS® are registered trademarks 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.
© 2019 Novo Nordisk  All rights reserved. US19NC00038  October 2019