NovoNordisk Instant Savings Card
RxBIN: 610524
RxPCN: Loyalty
RxGRP: 50776143
ISSUER: (80840)
ID: 972118280
To activate your card, call 1-855-292-5966 or visit www.novonordisksavingscard.com

a Eligible patients only. Terms & conditions:

b Selected products include Levemir® FlexPen®, NovoLog®, and NovoLog® Mix 70/30 FlexPen®

To the Patient: You must present this card to the pharmacist along with your prescription to participate in this program. If you have any questions regarding your eligibility or benefits, or if you wish to discontinue your participation, call the Novo Nordisk Instant Savings Card Program at 1-855-292-5966 (8:00 AM-8:00 PM EST, Monday-Friday). When you use this card, you are certifying that you understand the program rules, regulations, and terms and conditions. You are not eligible if prescriptions are paid by any state or other federally funded programs, including but not limited to Medicare or Medicaid, Medigap, VA, DOD or TriCare, or where prohibited by law; and you will otherwise comply with the terms above.

To the Pharmacist: When you use this card, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state or other governmental programs for this prescription.

When you use this card, you are certifying that you understand the program rules, regulations, and terms and conditions. You are not eligible if prescriptions are paid by any state or other federally funded programs, including, but not limited to Medicare or Medicaid, Medigap, VA, DOD or TriCare, or where prohibited by law; and you will otherwise comply with the terms above.

Pay no more than $25 when you start on a Novo Nordisk product and for each refill for up to 2 years, and no more than $20 for the next prescribed product and each refill for up to 2 years. The Novo Nordisk Instant Savings Card Program is inclusive of Levemir® FlexPen® (insulin detemir [rDNA origin] injection), NovoLog® (insulin aspart [rDNA origin] injection), or NovoLog® Mix 70/30 FlexPen® (70% insulin aspart protamine suspension and 30% insulin aspart injection, [rDNA origin]). Offer is valid for a maximum of 24 refills per product over the 2 years. Novo Nordisk reserves the right to modify or cancel this program at any time. Please deduct the amount of the discount from any claim for reimbursement submitted to your insurance company or plan.

Get 1 free box of Novo Nordisk needles when you activate your Instant Savings Card and enroll in the program. Limit 1 box of needles per person. Needles are sold separately and may require a prescription in some states. Needles and FlexPen® must not be shared. Offer limited to 1 card per patient. Offer not valid for claims that are submitted by or on behalf of a patient for reimbursement or coverage for Levemir® FlexPen®, NovoLog®, or NovoLog® Mix 70/30 FlexPen® under Medicaid, Medicare, TriCare, or any other federal or state government health care program. Offer not valid for Levemir® FlexPen®, NovoLog®, or NovoLog® Mix 70/30 FlexPen® reimbursed in full by any third party payor. Offer void where taxed, restricted, or prohibited.

Offer only good in the U.S.A. Eligibility is restricted to individuals; no clubs, groups, or organizations. This savings card is not transferable. If you need assistance with prescription drug costs, help may be available.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

McKesson Inc., Scottsdale, AZ 85251 Patent Pending

FlexPen®, Levemir®, and NovoLog® are registered trademarks of Novo Nordisk A/S.
© 2013 Novo Nordisk 0713-00017180-1 September 2013