Patient Assistance Program (PAP) Voucher
Terms and conditions:
This voucher is intended to allow a patient currently enrolled in the Novo Nordisk PAP to receive PAP product from a pharmacy (instead of the typical PAP shipment method).
This offer can only be used for the authorized product. Patient must have a valid prescription for the brand being filled. 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 will comply with the terms and conditions described herein. You will not seek, and have not sought, reimbursement for the medication received from any third party (including any insurer).
Medicare Part D beneficiaries acknowledge and agree that Novo Nordisk may use information provided to Novo Nordisk or its partners to report information about PAP enrollment to Part D plans. Medicare Part D beneficiaries further acknowledge and agree that any amounts paid in connection with this offer do not count towards True Out-of-Pocket (TrOOP).
Novo Nordisk’s Terms and Conditions and offer details may change from time to time without prior notice. This offer is valid in the United States, and its territories, unless prohibited by law and may be redeemed at participating retail pharmacies, and is intended for outpatient use only. Void where taxed, restricted, or prohibited by law. Not valid if reproduced.
This voucher cannot be combined with any coupon, certificate, voucher, or similar offer. No other purchase is necessary.
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:
If the Group # on your offer is [AV20027021] or [AV20027022]: This voucher is valid for a 120-day supply of the authorized product. Voucher is valid for one-time use only.
If the Group # on your offer is [AV20027023]: This voucher is valid for a 30-day supply of the authorized product. Voucher is valid for one-time use only.
Pharmacist:
When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any third-party or 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 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 for voucher (for all patients regardless of insurance status):
Patient is not eligible if he/she seeks reimbursement from any payer or prescription insurance plan.
If the patient has an offer with Group # [AV20027021] or [AV20027022]: The voucher is valid for a 120-day supply, one-time use, for one brand.
If the patient has an offer with Group # [AV20027023]: The voucher is valid for a 30-day supply, one-time use, for one brand.
For reimbursement, please submit electronically to SS&C Health using the BIN, PCN, GRP, and ID provided by patient. Reimbursement will be received from SS&C Health.
For any questions regarding SS&C Health online processing, please call the Pharmacist Help Desk at 1‑844‑373‑0987.