Saving Card

Here is your Wegovy® savings card
Take this to your pharmacist to get

your savings for Wegovy® .
AC20029003 29655867799
If you have questions about your savings card, please call

1-888-793-1218. Available 24 hours a day, 7 days a week.
Tips for getting started on Wegovy®
Present this card to your Get connected with your free

pharmacist when you pick up Health Coach and online resources
your Wegovy® prescription. at wegovy.com/login.html.
Please click here for Prescribing Information and Medication Guide or

visit www.novo-pi.com/wegovy.pdf.
Mail-order prescriptions
If you fill your prescription through a mail-order pharmacy or if you are
unable to have your card processed at the local pharmacy, please submit:
A photocopy of the front and back of your Wegovy® Savings

1 Program Card or the 11-digit ID number and GRP number
(beginning with AC)
Your original proof of purchase (original pharmacy receipt

2 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
3 Your date of birth
Mail all of the information to:

4 Wegovy Savings Card Claims Processing Dept.
PO Box 2355
Morristown, NJ 07962
Please allow 6-8 weeks to receive your reimbursement. Reimbursements are subject to
Program Terms, Conditions, and Eligibility Criteria.
Please click here for Prescribing Information and Medication Guide or visit
www.novo-pi.com/wegovy.pdf.
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 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 1-888-793-1218.
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 Card cannot be combined with any coupon, certificate, voucher, or similar offer. No other purchase
is necessary.
Patient is responsible for complying with any insurance carrier co-payment 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:
Patients who are commercially insured with product drug coverage, including those within their deductible
phase, may pay as little as (“PALA”) $25 per 28-day supply, $50 per 56-day supply, or $75 per 84-day supply
of Wegovy ®. Subject to a maximum savings of $200 per 28-day supply (“Savings Benefit”), $400 per 56-day
supply, or $600 per 84-day supply of Wegovy®. Cash-paying patients and commercially insured patients
without drug coverage can save up to $500 per 28-day supply, $1,000 per 56-day supply, or $1,500 per 84-day
supply of Wegovy®.
Patients redeeming this offer are 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 healthcare provider necessitating them to fill
an injection with a lower dosage strength for Wegovy®.
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 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 SS&C Health as a
Secondary Payer as a copay only billing using BIN 019158 and a valid Other Coverage Code (e.g. 8). The
patient is responsible initially for the PALA amount and the card pays up to the Savings Benefit.
Reimbursement will be received from SS&C Health.
Pharmacist instructions for a cash-paying patient:
Submit the claim to SS&C Health using BIN 019158. A valid Other Coverage Code (e.g. 1) is required. The
patient pay amount submitted will be reduced by up to the Savings Benefit and reimbursement 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.
Please click here for Prescribing Information and Medication Guide or visit
www.novo-pi.com/wegovy.pdf.
Wegovy® is a registered trademark of Novo Nordisk A/S.

Novo Nordisk is a registered trademark of Novo Nordisk A/S.
© 2022 Novo Nordisk All rights reserved. US21NC00031 January 2022

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Here is your Wegovy® savings card

Take this to your pharmacist to get

If you have questions about your savings card, please call

Tips for getting started on Wegovy®

Present this card to your Get connected with your free

Please click here for Prescribing Information and Medication Guide or

A photocopy of the front and back of your Wegovy® Savings

Your original proof of purchase (original pharmacy receipt

3 Your date of birth

Mail all of the information to:

Wegovy® is a registered trademark of Novo Nordisk A/S.

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