Do not share your Ozempic® pen with other people, even if the needle has been changed. You may give other people a serious infection or get a serious infection from them.
Diabetes Savings Offer Program
Novo Nordisk Savings Offer
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 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 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 patient information may be requested periodically to ensure accuracy of data and compliance with terms. Patients with questions about the savings offer may call 1‑877‑304‑6855.
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.
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 may be combined with a manufacturer-sponsored automatic eVoucher offer (at participating pharmacies) but cannot be combined with any other 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 cost-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 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 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, 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:
This offer is good for eligible patients purchasing up to a 90-day supply.
(a) OZEMPIC® (semaglutide) injection 0.5 mg, 1 mg, or 2 mg: As of January 2, 2025, pay as little as (“PALA”) $25, subject to a maximum savings of $100 per 1-month prescription, $200 per 2-month prescription, and $300 per 3-month prescription. The savings offer activation is valid for up to 48 months from date of enrollment. Month is defined as 28 days. In order to obtain the “PALA $25 per 3-month prescription” offer, the patient must have a prescription, written and dispensed for a 3-month supply, and the patient’s commercial insurance plan must provide coverage for a 3-month fill.
(b) RYBELSUS® (semaglutide) tablets 7 mg or 14 mg: This offer is good for eligible patients purchasing up to a 3-month prescription of RYBELSUS® 7 mg or 14 mg. RYBELSUS® 3 mg is limited to up to a 1-month prescription (30-day supply) per savings offer redemption.
- For commercially insured patients with RYBELSUS® coverage prescribed RYBELSUS® 3 mg: You may pay as little as (“PALA”) $10, subject to a maximum savings of $300 for each 1-month prescription. One month is defined as 30 days. This strength is limited to a 1-month prescription per savings offer redemption. The savings offer activation is valid for 48 months from the date of enrollment.
- For commercially insured patients with RYBELSUS® coverage prescribed RYBELSUS® 7 mg or 14 mg: You may pay as little as (“PALA”) $10, subject to a maximum savings of $300 per 1-month prescription, $600 per 2-month prescription, or $900 per 3-month prescription. One month is defined as 30 days. The savings offer activation is valid for 48 months from the date of enrollment. In order to obtain the “PALA $10 per 3-month prescription” offer, the patient must have a prescription, written and dispensed, for a 3-month supply, and the patient’s commercial insurance plan must provide coverage for a 3-month fill.
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. Offer excludes full cash-paying patients. 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 Help Desk at 1‑844‑373‑0987.
Mail-order prescriptions:
If you fill this prescription through a mail-order pharmacy or if you are unable to have this offer processed at the local pharmacy, reimbursement eligibility may be possible for any medication out-of-pocket costs.
- Download, print, and complete the reimbursement form found at NovoReimburse.com
- Mail the reimbursement form along with the following information:
- A copy of your Novo Nordisk Savings Offer, including the 10-digit GRP number (beginning with EC or AC) and the 11-digit ID number
- The original proof of purchase (original pharmacy receipt with patient’s name and address, pharmacy name, product name, NDC, prescription number or Rx number, date filled, quantity, and the overall price and copay/out-of-pocket expense paid)
- A legible photocopy of the front and back of your primary prescription insurance card
Mail all of the information to:
Novo Nordisk Savings Offer Claims Processing Dept.
PO Box 2355
Morristown, NJ 07962
Please allow 6-8 weeks to receive your 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.