Immediate Supply Voucher Program Terms & Conditions
Covered insulins:
- NovoLog® (insulin aspart) injection 100 U/mL
- NovoLog® Mix 70/30 (insulin aspart protamine and insulin aspart) injectable suspension 100 U/mL
- Levemir® (insulin detemir) injection 100 U/mLa
- Tresiba® (insulin degludec) injection 100 U/mL, 200 U/mL
- Fiasp® (insulin aspart) injection 100 U/mL
- Novolin® N (insulin isophane human) injectable suspension 100 U/mL
- Novolin® R (insulin human) injection 100 U/mL
- Novolin® 70/30 (insulin isophane human and insulin human) injectable suspension 100 U/mL
- Insulin Aspart Injection 100 U/mLb
- Insulin Aspart Protamine and Insulin Aspart Mix 70/30 Injectable Suspension 100 U/mLb
- Insulin Degludec Injection 100 U/mL, 200 U/mLb
Terms and conditions:
In order to redeem this offer, patient must have a valid prescription for a covered insulin and attest to being at risk of rationing insulin due to financial hardship. A valid Prescriber ID# is required on the prescription. Patient is not eligible where prohibited by law. 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 offer. Medicare Part D beneficiaries seeking to obtain insulin under the Immediate Supply Program must call 1-888-910-0454 to complete enrollment by providing Medicare Part D card details, Medicare Plan D Name, and Plan address among other information. Medicare Part D beneficiaries enrolling in the program acknowledge and agree that Novo Nordisk will use information provided to Novo Nordisk or its partners to report information about offer enrollment to Part D plans. Medicare Part D beneficiaries further acknowledge and agree that no part of the cost of the drug associated with this offer may count towards True Out of Pocket (TrOOP). The offer may only be used once per calendar year and expires 30 days after the date of registration. Novo Nordisk’s Eligibility and Restrictions, and Offer Details, may change from time to time without prior notice. For latest Terms and Conditions, please visit this page.
This offer is valid in the United States, may be redeemed at participating retail pharmacies, and is intended for outpatient use only. Availability of the offer in Massachusetts will be dependent upon state law in effect at the time patient presents the 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 per calendar year. Not valid if reproduced.
This 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. 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. Patients with questions may call 1-888-910-0784.
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 or apply the benefit received to the True Out-of-Pocket (TrOOP).
Pharmacist instructions:
Patient is not eligible if he/she seeks reimbursement from any payer or prescription insurance plan.
For reimbursement, please submit to SS&C Health using BIN 019158.
The free trial offer is valid for up to 35 mL of any combination of covered insulins. This voucher expires 30 days from the date of registration. The offer may be used once per calendar year.
For questions regarding SS&C Health online processing, please call the Pharmacy Help Desk at 1-844-373-0987.
aDiscontinuation Notice: Please be aware that Novo Nordisk will be discontinuing Levemir® in the US. This offer will continue to work for Levemir® FlexPen® and Levemir® vials while supplies last at your pharmacy. Before supplies are disrupted or discontinued, please talk to your health care provider about other options to continue your treatment. If you have any questions, please contact your health care provider or call the Novo Nordisk Customer Care Center at 1-800-727-6500.
bUnbranded biologic from Novo Nordisk Pharma, Inc. (NNPI)