Terms and conditions of use

Standard 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 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 patient information may be requested periodically to ensure accuracy of data and compliance with terms. Patients with questions about the savings offer may call 1‑888‑793‑1218.

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, 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

Wegovy^® (semaglutide) injection 2.4 mg:

For patients with commercial insurance who have coverage for Wegovy^®: As of January 2, 2025 (“Effective Date”), pay as little as (“PALA”) $0 or pay $650 for a 28-day supply of Wegovy^®, depending on your insurance coverage. If you are commercially insured with Wegovy^® coverage and your out-of-pocket expense with your commercial insurance is less than or equal to $849 per 28-day supply, you may pay as little as $0 and receive a maximum benefit of $225 per 28-day supply (1 box), $450 per 56-day supply (2 boxes), or $675 per 84-day supply (3 boxes). If you are commercially insured and your out-of-pocket expense with your commercial insurance is greater than $849 per 28-day supply (1 box), you can use this offer outside of your insurance and can expect to pay $650. Please note: If you are commercially insured and Wegovy^® is covered with an out-of-pocket expense that is above $849 per 28-day supply (eg, you have coinsurance or a high deductible), using this savings offer means your prescription will be processed outside of your insurance, will not count toward any deductibles, and cannot be applied to any insurance maximum out-of-pocket limits. 

For patients with commercial insurance who do not have coverage for Wegovy^® through their plan, or those who are cash-paying (government beneficiaries excluded): Pay $650 per 28-day supply (1 box), $1,300 per 56-day supply (2 boxes), or $1,950 per 84-day supply (3 boxes) of Wegovy^®.

This offer is available for all 5 different dose strengths of Wegovy^®.

Patients redeeming this offer may be eligible for additional savings if they are prescribed a dose de-escalation within 21 days after the date of fill for the original dose by their health care provider necessitating them to fill an injection with a lower dosage strength for Wegovy^®. For more information on eligibility and enrollment, please call 1‑833‑4‑WEGOVY (option 2).

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. 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. You also certify that you will not seek reimbursement for any benefit received through this offer.

Pharmacist instructions:

• For commercially insured patients with product coverage: 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 initially for the PALA amount, and the offer pays up to the Savings Benefit. Reimbursement will be received from SS&C Health.
• For commercially insured‐not covered patients: If Wegovy^® is not covered by the patient’s insurance, continue to process the savings offer as a Secondary Payer to BIN 019158 along with the patient’s insurance using Other Coverage Code 03. The patient is responsible for the first $650 per 28-day supply (1 box), $1,300 per 56-day supply (2 boxes), or $1,950 per 84-day supply (3 boxes) of Wegovy^®, and reimbursement will be received from SS&C Health.
• For cash-paying patients (who cannot be government beneficiaries), or where a commercially insured patient’s out-of-pocket expense is greater than $849 per 28-day supply: Submit the claim to SS&C Health using BIN 019158. A valid Other Coverage Code 01 is required. The patient is responsible for the first $650 per 28-day supply (1 box), $1,300 per 56-day supply (2 boxes), or $1,950 per 84-day supply (3 boxes) of Wegovy^®, 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.

Mail-order prescriptions

If you fill this prescription through a mail-order pharmacy or if you are unable to have this offer processed at a local pharmacy, reimbursement eligibility may be possible for any medication out-of-pocket costs.

1. Download, print, and complete the reimbursement form found at NovoReimburse.com
2. Mail the reimbursement form along with the following information:
   
   
   1. A copy of the Wegovy^® Savings Offer, including the 10-digit GRP number (beginning with EC or AC) and the 11-digit ID number
   2. The original proof of purchase (original pharmacy receipt with patient's name and address, pharmacy name, product name, NDC number, prescription or Rx number, date filled, quantity, and the overall price and copay/out-of-pocket expense paid)
   3. A legible photocopy of the front and back of the 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 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.