State insulin affordability program
Eligibility and restrictions:
In order for a pharmacy to redeem this offer, the patient must either satisfy the emergent prescription insulin supply eligibility criteria as determined by the insulin affordability legislation in their state of residence or have completed an application as required by their state insulin affordability legislation for continued support, that was reviewed and approved by the pharmacist in that state. In all instances, patient must first have a valid prescription for the medication(s) being filled.
A valid Prescriber ID# is required on the prescription. Patient is not eligible for continued support for the state insulin affordability program 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. 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.
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 patient information may be requested periodically to ensure accuracy of data and compliance with terms.
This offer, whether under the emergency supply provisions or insulin affordability program for continued support under state law, may be redeemed by participating retail pharmacies in that state. This offer is not transferable and is not valid if reproduced.
This voucher cannot be combined with any coupon, certificate, voucher, or similar offer. No other purchase is necessary.
Patient is responsible for complying with any insurance carrier co-payment disclosure requirements, including disclosing any savings received from this program. Novo Nordisk intends that all savings from this offer accrues to the patient. 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.
Emergency prescription insulin supply offer details:
Patients who are approved by a pharmacist to meet the eligibility requirements of their state insulin affordability program will Pay $0 for a one-time 30-day supply of covered insulin with a valid prescription for insulin, where patient has less than a seven (7) day supply of insulin available. Offer is limited to one voucher per patient per calendar year per covered NDC. The 2 prescriptions must be filled at a participating pharmacy in their state of residence as outlined by the law.
Insulin affordability program for continued support offer details:
Patients who are approved by a pharmacist to meet the eligibility requirements of their state insulin affordability program legislation will Pay $0 per 30-day supply of covered insulin. The pharmacy must call 1-833-538-0027 to obtain an ID for each prescription each month that the patient is deemed eligible. The prescriptions must be filled at a participating pharmacy in their state of residence as outlined by the law.
Pharmacist:
When you apply this offer, you are certifying that you will not submit 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 and that you will not seek reimbursement from any insurer for any benefit received through this card. You also certify that you will not collect a copayment from the individual to cover the pharmacy’s cost of processing and dispensing the insulin.
Pharmacist Instructions for voucher (for all patients regardless of insurance status):
Patient is not eligible if he/she seeks reimbursement from any payer or prescription insurance plan.
The voucher is valid up to a 30-day supply, one-time use, for one brand
For reimbursement, please submit electronically to SS&C Health using the BIN, PCN, GRP, and ID. Reimbursement will be received from SS&C Health.
For any questions regarding SS&C Health online processing, please call the Pharmacist Help Desk at 1-844-373-0987.