Eligibility and restrictions for Novo Nordisk Savings Offer program
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 seeks reimbursement under such a government program, or where prohibited by law. 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. Patient must be enrolled in 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. This offer is not valid when the entire cost of the 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 the patient meets the eligibility criteria, 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 1‑844‑590‑0570.
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 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 is provided solely for the benefit of the patient. This savings offer cannot be combined with any coupon, certificate, voucher, or similar offer. This includes, without limitation, any program offered through a third-party payer or pharmacy benefits manager, or an agent of either, that adjusts costs-sharing obligations. No other purchase is necessary.
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 the patient to enroll in a manufacturer copay assistance program, including:
- Programs in which payments made by the patient that are subsidized by manufacturer savings offer programs do not count toward their 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 the patient’s insurer has implemented these types of programs, the patient will not be eligible for and agrees 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 the patient’s per-claim maximum savings benefit and/or the patient’s annual maximum savings benefit. If you learn that the patient’s 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 the patient is subject to an accumulator adjustment or copay maximizer program when the patient enrolls in the Novo Nordisk saving program, Novo Nordisk will monitor program utilization data and reserves the right to reduce, discontinue, or otherwise modify this savings offer at any time, 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:
- NovoSeven® RT (coagulation Factor VIIa, recombinant), Novoeight® (antihemophilic factor, recombinant), Tretten® (Coagulation Factor XIII A-Subunit [Recombinant]), Rebinyn® Coagulation Factor IX (Recombinant), GlycoPEGylated, and/or Esperoct® [antihemophilic factor (recombinant), glycopegylated-exei]: Commercially insured patients with product coverage under their insurer’s pharmacy or medical benefit, including those within their deductible phase, may pay as little as $0 per fill, subject to a maximum savings on the patient’s out-of-pocket drug costs of up to $15,000 per calendar year. After reaching the maximum program benefit, the patient will be responsible for all remaining out-of-pocket expenses. This savings offer is valid for 48 months from the date of enrollment and can be used toward any of the listed brands. The annual maximum savings of $15,000 will reset every January 1 until program expiration.
- Alhemo® (concizumab-mtci) injection 60 mg, 150 mg, 300 mg pens: Commercially insured patients with product coverage under their insurer’s pharmacy or medical benefit, including those within their deductible phase, may pay as little as $0 per fill, subject to a maximum savings on the patient’s out-of-pocket drug costs of up to $15,000 per calendar year. After reaching the maximum program benefit, the patient will be responsible for all remaining out-of-pocket expenses. This savings offer is valid for 48 months from the date of enrollment, and the annual maximum savings of $15,000 will reset every January 1 until program expiration.
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 offer.
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 SS&C Health as a Secondary Payer using BIN 019158 with patient responsibility amount and a valid Other Coverage Code (eg, 8). The patient is responsible initially for the PALA amount, and the offer pays up to the Savings Benefit. Reimbursement will be received from SS&C Health. Pharmacy must submit a claim within 180 days from the date the prescription was filled. For any questions regarding SS&C online processing, please call the Help Desk at 1-844-373-0987.
Provider instructions for medical claims:
To request reimbursement for medical claims, providers can request a copay expenditure form and instructions by calling the ConnectiveRx Claims Processing Center at 1‑844‑590‑0570. Participation in this program must comply with all applicable laws and regulations as a 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. Reimbursement will be received from ConnectiveRx.
Please send the completed form and all required documentation to the following address and/or fax number:
Copay Assistance Program
C/O ConnectiveRx Claims Processing Center
P.O. Box 2355
Morristown, NJ 07962
FAX: 1-908-809-6239
Please allow 6-8 weeks to receive the reimbursement. Reimbursements are subject to Program Terms, Conditions, and Eligibility Criteria. Requests must be received within 180 days from the date the prescription was filled. Medication filled prior to enrollment in this program will not be eligible for copay assistance and cannot be reimbursed.
If you have any questions regarding the copay expenditure form or the copay process for Novo Nordisk's medicines administered to a commercially insured patient under their insurance plan’s medical benefit, please contact Copay Assistance Program at 1‑844‑590‑0570.