Terms and Conditions

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 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 where prohibited by law. Patients enrolled in a federal or state health care program may not use this program even if they elect to be processed as an uninsured (cash-paying) patient. Patients are also ineligible for this offer if they are Medicare-eligible and enrolled in an employer-sponsored group waiver health plan (EGWP) or government-subsidized prescription drug benefit program for retirees. Note: The Federal Employees Health Benefits (FEHB) Program, Affordable Care (Health Exchange) Plans, and insurance provided through state employee plans are NOT federal or state government health care programs for purposes of this savings offer. 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. Medication filled prior to enrollment in this program will not be eligible for copay assistance and cannot be reimbursed. 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 offer. 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. Reconfirmation of information may be requested periodically to ensure accuracy of data and compliance with terms. Patients with questions about the savings offer may call 1‑833‑992‑3299.

This offer is valid in the United States and its territories, unless prohibited by law, 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 noninsurance 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.

Patient is responsible for complying with any insurance carrier copayment disclosure requirements, including disclosing any savings received from this program. Novo Nordisk intends that all savings from this offer accrue to the patient and are intended to be credited toward patient out-of-pocket obligations and maximums, including applicable copayments, coinsurance, and deductibles. Some insurance plans have established programs that require you to enroll in a manufacturer copay assistance program, including:

Programs in which payments made by you that are subsidized by manufacturer savings offer programs do not count toward your deductibles or other patient out-of-pocket cost-sharing amounts (eg, accumulator adjustment programs); and/or

Programs that adjust patient out-of-pocket cost-sharing amounts based on the availability of a manufacturer savings offer (eg, maximizer programs)

Except where prohibited by law, if your insurer has implemented these types of programs, you will not be eligible for and agree not to use this savings program, and Novo Nordisk reserves the right to reduce or discontinue financial assistance under this savings program, including, but not limited to, reducing your per-claim maximum savings benefit and/or your annual maximum savings benefit. If you learn that your insurance company or health plan has implemented either an accumulator adjustment program or a copay maximizer program, you agree to inform Novo Nordisk. Since you may be unaware whether you are subject to an accumulator adjustment or copay maximizer program when you enroll in the Novo Nordisk savings program, Novo Nordisk will monitor program utilization data and reserves the right to reduce, discontinue, or otherwise modify this savings offer at any time, and with or without notice.

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.

Offer Details:

ZEGALOGUE^® (dasigulcagen) injection 0.6 mg/0.6 mL: Depending on insurance coverage and out-of-pocket responsibility, you may pay $35 or $99 for each one-pack prescription for up to 48 months from date of savings offer activation. This offer is limited to (2) one-packs or (1) two-pack of the ZEGALOGUE^® Single-dose Autoinjector or Single-dose Prefilled Syringe per prescription fill.

If you are commercially insured with drug coverage and your out-of-pocket expense with your commercial insurance is less than or equal to $100, you will pay $35 and receive a maximum savings benefit of $65.
If you are commercially insured without drug coverage or your out-of-pocket expense with your commercial insurance is greater than $100 or you do not have insurance/cash-pay, with this offer, you will pay $99 per one-pack or pay $198 per two-pack. This offer will work outside of your insurance, will not count toward any deductibles, and cannot be applied to a patient’s true out-of-pocket costs.

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 applying this offer, you agree that patients enrolled in a federal or state health care program may not use this program even if they elect to be processed as an uninsured (cash-paying) patient. 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.

Pharmacist instructions:

For commercially insured patients with coverage and an out-of-pocket expense less than or equal to $100: Submit the claim to the patient’s primary insurance first, then submit the balance due to SS&C Health as a Secondary Payer as a copay-only billing using BIN 019158 and a valid Other Coverage Code 08. The patient is responsible for $35, and the offer pays up to the Savings Benefit of $65. Reimbursement will be received from SS&C Health.
For commercially insured – not covered patients, or where the patient’s out-of-pocket expense is greater than $100, or for uninsured cash-pay patients (who cannot be government beneficiaries): Submit the claim to SS&C Health using BIN 019158. A valid Other Coverage Code 01 is required. The patient is responsible for $99 per one-pack or $198 per two-pack, and reimbursement will be received from SS&C Health.
Pharmacy must submit claim within 180 days from the date the prescription was filled. For any questions regarding SS&C online processing, please call the Pharmacy Help Desk at 1‑844‑373‑0987.