Rivfloza^® (nedosiran) injection 80 mg, 128 mg, or 160 mg Savings Offer Program

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 seeks reimbursement under such a Government Program, or where prohibited by law. 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. By using this offer, you are certifying that you meet the eligibility criteria, 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 information may be requested periodically to ensure accuracy of data and compliance with terms. Patients with questions about the Savings Offer may call 1‑833‑664‑5443.

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. Void where taxed, restricted, or prohibited by law. This offer is not transferable and is limited to 1 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 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.

Offer Details:

Commercially insured patients with Rivfloza^® (nedosiran) injection coverage, including those within their deductible phase, may pay as little as (“PALA”) $0 per fill, subject to a maximum savings on patient’s out-of-pocket drug costs of up to $15,000 per calendar year. After reaching the maximum program benefit, the patient will be responsible for all remaining out-of-pocket expenses. The Savings Offer is valid for 48 months from the date of enrollment, and the annual maximum savings of $15,000 will reset every January 1^st until program expiration.

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:

For commercially insured patients with product coverage: 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 offer pays up to $15,000 per calendar year. After reaching the maximum program benefit, the patient will be responsible for all remaining out-of-pocket expenses. Offer excludes full cash-paying patients. Reimbursement will be received from SS&C Health. For any questions regarding SS&C Health online processing, please call the Help Desk at 1‑844‑373‑0987.

Mail-order prescriptions:

If you fill a 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 Rivfloza^® 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.