^bNovo Nordisk Hemophilia and Rare Bleeding Disorders Copay/Coinsurance Terms and Conditions:
Enrolled patients are eligible for up to $12,000 in co-pay/coinsurance assistance per calendar year for each NNI hemophilia or rare bleeding disorder product. Assistance is retroactive to 60 days. Patients must be commercially insured and may not be participating in any government, state, or federally funded medical or prescription benefit programs, including Medicare, Medicaid, Medigap, VA, DOD, and TRICARE, including patients who participate in a managed Medicaid program or have Medicaid as secondary insurance. Uninsured, cash-paying patients are not eligible to participate. Patients are eligible to receive co-pay/
coinsurance assistance on an annual basis (12 months). Offer good only in the USA, Puerto Rico, Guam, Saipan, and Virgin Islands with participating pharmacies and cannot be redeemed at government-subsidized clinics. Void where taxed, restricted, or prohibited by law. The Savings Card is no longer valid for residents of Massachusetts. Patient is responsible for complying with any insurance carrier co-payment disclosure requirements, including disclosing any savings received from this program. Re-confirmation of information may be requested periodically to ensure accuracy of data and compliance with terms. This is not an insurance program. Novo Nordisk reserves the right to rescind, revoke, or amend this offer without notice at any time. Non-medication expenses, such as ancillary supplies or administration-related costs, are not eligible. Must have a current prescription for an FDA-approved indication.
^cThe Novo Nordisk Patient Assistance Program (PAP) is administered by [NovoCare^®] To qualify for the PAP, patients must demonstrate financial need and must have attempted to find alternative reimbursement. Several factors are considered in evaluating financial need, including cost of living, size of household, and burden of total medical expenses. If the applicant qualifies under the PAP guidelines, a limited supply of the requested medication(s) will be shipped to the patient. Patients who qualify for PAP may be eligible to receive the prescribed Novo Nordisk product, for up to 1 year from the approval date. Product limits vary.
^dPatients who have been prescribed a Novo Nordisk hemophilia and rare bleeding disorder product for an FDA-approved indication, and who have commercial insurance, may be eligible to receive a limited supply of free product. Patients who participate in any government, state, or federally funded medical or prescription benefit programs, including Medicare, Medicaid, Medigap, VA, DOD, and TRICARE, including patients who participate in a managed Medicaid program or have Medicaid as secondary insurance, are not eligible to receive product support. Product is provided at no cost to the patient or the HCP, is not contingent on any product purchase, and the patient and HCP must not: (1) bill any third party for the free product, or (2) resell the free product.