Diabetes Savings Offer Program
Novo Nordisk 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. 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 and will comply with the terms and conditions described herein and will not seek reimbursem*nt 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 1‑877‑304‑6855.
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 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:
This offer is good for eligible patients purchasing up to a 90‑day supply.
(a) OZEMPIC® (semaglutide) injection 0.5 mg, 1 mg, or 2 mg: Pay as little as (“PALA”) $25, subject to a maximum savings of $150 per 1‑month prescription, $300 per 2‑month prescription, or $450 per 3-month prescription, for up to 48 months from the date of Savings Offer activation. Month is defined as 28 days. In order to obtain the “PALA $25 per 3-month prescription” offer, the patient must have a prescription for a 3-month supply, and the patient’s commercial insurance plan must provide coverage for a 3‑month fill.
(b) RYBELSUS® (semaglutide) tablets 7 mg or 14 mg:
This offer is good for eligible patients purchasing up to a 3‑month prescription of RYBELSUS® 7 mg or 14 mg. RYBELSUS® 3 mg is limited to up to a 1‑month prescription (30-day supply) per savings offer redemption.
- For commercially insured patients with RYBELSUS® coverage prescribed RYBELSUS® 3 mg: You may pay as little as (“PALA”) $10, subject to a maximum savings of $300 for each 1‑month prescription. One month is defined as 30 days. This strength is limited to a 1‑month prescription per Savings Offer redemption. The Savings Offer activation is valid for 48 months from the date of enrollment.
- For commercially insured patients with RYBELSUS® coverage prescribed RYBELSUS® 7 mg or 14 mg: You may pay as little as (“PALA”) $10, subject to a maximum savings of $300 per 1‑month prescription, $600 per 2‑month prescription, or $900 per 3‑month prescription. One month is defined as 30 days. The Savings Offer activation is valid for 48 months from the date of enrollment.
Pharmacist:
When you apply this offer, you are certifying that you have not submitted a claim for reimbursem*nt 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 reimbursem*nt for any benefit received through this offer.
Pharmacist instructions for a patient with an Eligible Third Party:
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 patient is responsible initially for the PALA amount and the offer pays up to the Savings Benefit. Offer excludes full cash-paying patients. Reimbursem*nt will be received from SS&C Health. For any questions regardingSS&C online processing, please call the Help Desk at 1‑844‑373‑0987.
Mail-order prescriptions
If you fill your prescription through a mail-order pharmacy or if you are unable to have your offer processed at the local pharmacy, please submit:
- A copy of your Diabetes Savings Offer, including the 11-digit ID number and GRP number (beginning with EC)
- Your original proof of purchase (original pharmacy receipt with your name and address, pharmacy name, product name, prescription numbers, NDC number, date filled, quantity, and price) and a photocopy of the front and back of your insurance card
- Your date of birth
- Mail all of the information to:
Savings Offer Claims Processing Dept.
PO Box 2355
Morristown, NJ 07962
Please allow 6-8 weeks to receive your reimbursem*nt. Reimbursem*nts are subject to Program Terms, Conditions, and Eligibility Criteria.
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Important Safety Information for Ozempic®
Do not share your Ozempic®pen with other people, even if the needle has been changed. You may give other people a serious infection, or get a serious infection from them.
What is the most important information I should know about Ozempic®?
Ozempic®may cause serious side effects, including:
- Possible thyroid tumors, including cancer. Tell your health care provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, Ozempic® and medicines that work like Ozempic® caused thyroid tumors, including thyroid cancer. It is not known if Ozempic® will cause thyroid tumors or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people.
- Do not use Ozempic® if you or any of your family have ever had MTC, or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
What is Ozempic®?
Ozempic® (semaglutide) injection 0.5 mg, 1 mg, or 2 mg is an injectable prescription medicine used:
- along with diet and exercise to improve blood sugar (glucose) in adults with type 2 diabetes mellitus.
- to reduce the risk of major cardiovascular events such as heart attack, stroke, or death in adults with type 2 diabetes mellitus with known heart disease.
It is not known if Ozempic® can be used in people who have had pancreatitis.
Ozempic® is not for use in people with type 1 diabetes.
It is not known if Ozempic® is safe and effective for use in children under 18 years of age.
Important Safety Information
Do not use Ozempic® if:
- you or any of your family have ever had MTC or if you have MEN 2.
- you are allergic to semaglutide or any of the ingredients in Ozempic®. See symptoms of serious allergic reaction in “What are the possible side effects of Ozempic®?”.
Before using Ozempic®, tell your health care provider if you have any other medical conditions, including if you:
- have or have had problems with your pancreas or kidneys.
- have a history of diabetic retinopathy.
- are pregnant or breastfeeding or plan to become pregnant or breastfeed. It is not known if Ozempic®will harm your unborn baby or passes into your breast milk. You should stop using Ozempic®2 months before you plan to become pregnant.
Tell your health care provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, herbal supplements, and other medicines to treat diabetes, including insulin or sulfonylureas.
What are the possible side effects of Ozempic®?
Ozempic®may cause serious side effects, including:
- inflammation of your pancreas (pancreatitis).Stop using Ozempic®and call your health care provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back.
- changes in vision.Tell your health care provider if you have changes in vision during treatment with Ozempic®.
- low blood sugar (hypoglycemia).Your risk for getting low blood sugar may be higher if you use Ozempic®with another medicine that can cause low blood sugar, such as a sulfonylurea or insulin.Signs and symptoms of low blood sugar may include:dizziness or lightheadedness, blurred vision, anxiety, irritability or mood changes, sweating, slurred speech, hunger, confusion or drowsiness, shakiness, weakness, headache, fast heartbeat, and feeling jittery.
- kidney problems (kidney failure).In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration), which may cause kidney problems to get worse. It is important for you to drink fluids to help reduce your chance of dehydration.
- serious allergic reactions.Stop using Ozempic® and get medical help right away if youhave any symptoms of a serious allergic reaction, including swelling of your face, lips, tongue, or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heartbeat.
- gallbladder problems.Gallbladder problems have happened in some people who take Ozempic®. Tell your healthcare provider right away if you get symptoms which may include: pain in your upper stomach (abdomen), fever, yellowing of the skin or eyes (jaundice), or clay-colored stools.
The most common side effects of Ozempic®may includenausea, vomiting, diarrhea, stomach (abdominal) pain, and constipation.
Please seePrescribing InformationandMedication Guide for Ozempic®.
Ozempic®is a prescription medication.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visitwww.fda.gov/medwatchor call1‑800‑FDA‑1088.
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Important Safety Information for RYBELSUS®
What is the most important information I should know about RYBELSUS®?
RYBELSUS®may cause serious side effects, including:
- Possible thyroid tumors, including cancer. Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, RYBELSUS®and medicines that work like RYBELSUS®caused thyroid tumors, including thyroid cancer. It is not known if RYBELSUS®will cause thyroid tumors or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people
Do not use RYBELSUS®if:
- you or any of your family have ever had MTC, or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
- you have had a serious allergic reaction to semaglutide or any of the ingredients in RYBELSUS®. See symptoms of serious allergic reaction in“What are the possible side effects of RYBELSUS®?”
What is RYBELSUS®?
RYBELSUS®(semaglutide) tablets 7 mg or 14 mg is a prescription medicine used along with diet and exercise to improve blood sugar (glucose) in adults with type 2 diabetes.
- It is not known if RYBELSUS®can be used in people who have had pancreatitis
- RYBELSUS®is not for use in people with type 1 diabetes
- It is not known if RYBELSUS®is safe and effective for use in children under 18 years of age
Important Safety Information
Before using RYBELSUS®, tell your healthcare provider if you have any other medical conditions, including if you:
- have or have had problems with your pancreas or kidneys
- have a history of vision problems related to your diabetes
- are pregnant or plan to become pregnant. It is not known if RYBELSUS®will harm your unborn baby. You should stop using RYBELSUS®2 months before you plan to become pregnant. Talk to your healthcare provider about the best way to control your blood sugar if you plan to become pregnant or while you are pregnant
- are breastfeeding or plan to breastfeed. Breastfeeding is not recommended during treatment with RYBELSUS®
Tell your healthcare provider about all the medicines you take,including prescription and over-the-counter medicines, vitamins, and herbal supplements. RYBELSUS®may affect the way some medicines work and some medicines may affect the way RYBELSUS®works.
How should I take RYBELSUS®?
- Take RYBELSUS®exactly as your healthcare provider tells you to
- Take RYBELSUS®by mouth on an empty stomach when you first wake up with a sip of plain water (no more than 4 ounces)
- Do not split, crush, or chew. Swallow RYBELSUS®whole
- After 30 minutes, you can eat, drink, or take other oral medicines
- If you miss a dose of RYBELSUS®, skip the missed dose and go back to your regular schedule
What are the possible side effects of RYBELSUS®?
RYBELSUS®may cause serious side effects, including:
- inflammation of your pancreas (pancreatitis).Stop using RYBELSUS®and call your healthcare provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back
- changes in vision.Tell your healthcare provider if you have changes in vision during treatment with RYBELSUS®
- low blood sugar (hypoglycemia).Your risk for getting low blood sugar may be higher if you use RYBELSUS®with another medicine that can cause low blood sugar, such as a sulfonylurea or insulin.Signs and symptoms of low blood sugar may include:dizziness or lightheadedness, blurred vision, anxiety, irritability or mood changes, sweating, slurred speech, hunger, confusion or drowsiness, shakiness, weakness, headache, fast heartbeat, and feeling jittery
- kidney problems (kidney failure).In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration), which may cause kidney problems to get worse. It is important for you to drink fluids to help reduce your chance of dehydration
- serious allergic reactions.Stop using RYBELSUS®and get medical help right away, if you have any symptoms of a serious allergic reaction, including swelling of your face, lips, tongue, or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heartbeat
- gallbladder problems. Gallbladder problems have happened in some people who take RYBELSUS®. Tell your healthcare provider right away if you get symptoms of gallbladder problems, which may include: pain in your upper stomach (abdomen), yellowing of skin or eyes (jaundice), fever, and clay-colored stools
The most common side effects of RYBELSUS®may includenausea, stomach (abdominal) pain, diarrhea, decreased appetite, vomiting, and constipation. Nausea, vomiting, and diarrhea are most common when you first start RYBELSUS®.
Please seePrescribing Information and Medication Guide for RYBELSUS®.
RYBELSUS® is a prescription medication.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visitwww.fda.gov/medwatchor call1‑800‑FDA‑1088.
