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 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 1‑888‑793‑1218.
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 May 30, 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) ofWegovy®.
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 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 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. Reimbursem*nt 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) ofWegovy®, and reimbursem*nt 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) ofWegovy®, and reimbursem*nt 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 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 Wegovy® Savings Offer, including the 11-digit ID number and GRP number (beginning with AC)
- 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:
Wegovy® 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.Medication filled prior to enrollment in this program will not be eligible for copay assistance and cannot be reimbursed.
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Important Safety Information for Wegovy®
What is the most important information I should know about Wegovy®?
Wegovy® 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, Wegovy® and medicines that work like Wegovy® caused thyroid tumors, including thyroid cancer. It is not known if Wegovy® will cause thyroid tumors or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people
- Do not use Wegovy® if you or any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC) or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
What is Wegovy®?
Wegovy® (semaglutide) injection 2.4 mg is an injectable prescription medicine used with a reduced calorie diet and increased physical activity:
- to reduce the risk of major cardiovascular events such as death, heart attack, or stroke in adults with known heart disease and with either obesity or overweight.
- that may help adults and children aged 12 years and older with obesity, or some adults with overweight who also have weight-related medical problems, to help them lose excess body weight and keep the weight off.
Wegovy® contains semaglutide and should not be used with other semaglutide-containing products or other GLP-1 receptor agonist medicines.
It is not known if Wegovy® is safe and effective for use in children under 12 years of age.
Important Safety Information
Do not use Wegovy® if:
- you or any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (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 Wegovy®
Before using Wegovy®, 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 type 2 diabetes and a history of diabetic retinopathy
- have or have had depression, suicidal thoughts, or mental health issues
- are pregnant or plan to become pregnant. Wegovy® may harm your unborn baby. You should stop using Wegovy® 2 months before you plan to become pregnant
- are breastfeeding or plan to breastfeed. It is not known if Wegovy® passes into your breast milk
Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Wegovy® may affect the way some medicines work and some medicines may affect the way Wegovy® works. Tell your healthcare provider if you are taking other medicines to treat diabetes, including sulfonylureas or insulin. Wegovy® slows stomach emptying and can affect medicines that need to pass through the stomach quickly.
What are the possible side effects of Wegovy®?
Wegovy® may cause serious side effects, including:
- inflammation of your pancreas (pancreatitis). Stop using Wegovy® 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
- gallbladder problems. Wegovy® may cause gallbladder problems, including gallstones. Some gallstones may need surgery. Call your healthcare provider if you have symptoms, such as pain in your upper stomach (abdomen), fever, yellowing of the skin or eyes (jaundice), or clay-colored stools
- increased risk of low blood sugar (hypoglycemia), especially those who also take medicines for diabetes such as insulin or sulfonylureas.This can be a serious side effect. Talk to your healthcare provider about how to recognize and treat low blood sugar and check your blood sugar before you start and while you take Wegovy®. Signs and symptoms of low blood sugar may include dizziness or light-headedness, blurred vision, anxiety, irritability or mood changes, sweating, slurred speech, hunger, confusion or drowsiness, shakiness, weakness, headache, fast heartbeat, or 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 Wegovy® 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
- change in vision in people with type 2 diabetes. Tell your healthcare provider if you have changes in vision during treatment with Wegovy®
- increased heart rate. Wegovy® can increase your heart rate while you are at rest. Tell your healthcare provider if you feel your heart racing or pounding in your chest and it lasts for several minutes
- depression or thoughts of suicide. You should pay attention to any mental changes, especially sudden changes in your mood, behaviors, thoughts, or feelings. Call your healthcare provider right away if you have any mental changes that are new, worse, or worry you
The most common side effects of Wegovy® may include: nausea, diarrhea, vomiting, constipation, stomach (abdomen) pain, headache, tiredness (fatigue), upset stomach, dizziness, feeling bloated, belching, low blood sugar in people with type 2 diabetes, gas, stomachflu, heartburn, and runny nose or sore throat.
Please seePrescribing Information and Medication Guide for Wegovy®.
Wegovy®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.
