Savings Card Program for Saxenda® (liraglutide) injection 3 mg
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 participates in or seeks reimbursement or submits a claim for reimbursement to 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. 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 card. 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. Re-confirmation of information may be requested periodically to ensure accuracy of data and compliance with terms. Patients with questions about the Savings Card offer may call 1-877-304-6895.
This offer is valid in the United States and may be redeemed at participating retail pharmacies. Absent a change in Massachusetts law, effective January 1, 2021, the Savings Card will no longer be valid for residents of Massachusetts. Void where taxed, restricted, or prohibited by law. 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 Card cannot be combined with any coupon, certificate, voucher, or similar offer.
Patient is responsible for complying with any insurance carrier co-payment 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 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: Patients who are commercially insured may pay as little as (“PALA”) $25 per 30-day supply (1 box), $50 per 60-day supply (2 boxes), or $75 per 90-day supply (3 boxes) of Saxenda®. Subject to a maximum savings of $200 per 30-day supply (1 box) (“Savings Benefit”), $400 per 60-day supply (2 boxes), or $600 per 90-day supply (3 boxes) of Saxenda®. Cash-paying patients and commercially insured patients without drug coverage can save up to $200 per 30-day supply (1 box) (“Savings Benefit”), $400 per 60-day supply (2 boxes), or $600 per 90-day supply (3 boxes) of Saxenda®. Both offers are valid for up to 24 months from the date of Savings card activation and subject to a maximum of twelve 30-day prescriptions (12 boxes) per calendar year.
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 card.
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 CHANGE HEALTHCARE as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code, (eg, 8). The patient is responsible initially for the PALA amount and the card pays up to the Savings Benefit. Reimbursement will be received from CHANGE HEALTHCARE.
Pharmacist instructions for a cash-paying patient:
Submit this claim to CHANGE HEALTHCARE. A valid Other Coverage Code (eg, 1) is required. The patient pay amount submitted will be reduced by up to the Savings Benefit and reimbursement will be received from CHANGE HEALTHCARE.
For any questions regarding CHANGE HEALTHCARE online processing, please call the Help Desk at 1-800-433-4893.