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. 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. 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 non-insurance 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 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. 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 accrues to the patient. 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 and have coverage for Wegovy^®, including those within their deductible phase: As of January 2, 2024 (“Effective Date”), pay as little as (“PALA”) $0 for up to thirteen (13) 28‑day fills (1 box) of Wegovy^®, subject to a maximum savings of $225 per 28‑day supply (1 box) (“Savings Benefit”), $450 per 56-day supply (2 boxes), or $675 per 84‑day supply (3 boxes). After the patient’s thirteenth (13th) 28‑day fill, patients may then pay as little as (“PALA”) $25 per 28‑day supply (1 box), $50 per 56-day supply (2 boxes), or $75 per 84-day supply (3 boxes) of Wegovy^®. Subject to a maximum savings of $200 per 28‑day supply (1 box), $400 per 56‑day supply (2 boxes), or $600 per 84‑day supply (3 boxes) of Wegovy^®.

For patients with commercial insurance who do not have coverage for Wegovy^® through their plan, or those that are cash-paying (who cannot be government beneficiaries): As of April 29, 2024 (“Effective Date”), 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. 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): 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.
• 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 (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.