Diabetes New Card Request
Diabetes Activate Card

Please read the PRIVACY OPT-IN language below, word for word.

You have selected that you do not have a Novo Nordisk Diabetes Savings Card and are calling to determine eligibility. Before we proceed, please listen closely to the following privacy statement about the eligibility process:

Novo Nordisk values your privacy and the security of your personal information, which we will need to collect from you for the sole purpose of determining your eligibility, enrollment, and/or activation of the Novo Nordisk Diabetes Savings Card along with other purposes to aid you in your Diabetes journey. Specifically, if you are deemed eligible for a Savings Card, you understand that certain information pertaining to your use of the Savings Card may be shared by your pharmacy with Novo Nordisk, the sponsor of the Card. The information disclosed will include the date a prescription was filled, the amount of medication dispensed by the pharmacist, and potentially the amount reimbursed by Novo Nordisk. This information may be used by Novo Nordisk to provide you with information about your prescription along with critical analytics for Novo Nordisk to make program improvements to the Novo Nordisk Diabetes Savings Card. Should you begin receiving prescription benefits from a federal, state, or other government-funded program at any time, you will no longer be eligible to participate in this program. You can learn more about your privacy rights at www.novonordisk-us.com/disclaimer-privacy.html.

Do you understand and agree that you are releasing only the minimally necessary information, including your first name, last name, email address, zip code, and status as a patient or caregiver (along with the other general information mentioned) to Novo Nordisk and authorized agents working on its behalf in order to assist you with enrolling for the Novo Nordisk Diabetes Savings Card?

You have selected that you already have a Novo Nordisk Diabetes Savings Card and are calling to activate it. Before we proceed, please listen closely to the following privacy statement about the activation process:

Novo Nordisk values your privacy and the security of your personal information, which we will need to collect from you for the sole purpose of determining your eligibility, enrollment, and/or activation of the Novo Nordisk Diabetes Savings Card along with other purposes to aid you in your Diabetes journey. Specifically, if you are deemed eligible for a Savings Card, you understand that certain information pertaining to your use of the Savings Card may be shared by your pharmacy with Novo Nordisk, the sponsor of the Card. The information disclosed will include the date a prescription was filled, the amount of medication dispensed by the pharmacist, and potentially the amount reimbursed by Novo Nordisk. This information may be used by Novo Nordisk to provide you with information about your prescription along with critical analytics for Novo Nordisk to make program improvements to the Novo Nordisk Diabetes Savings Card. Should you begin receiving prescription benefits from a federal, state, or other government-funded program at any time, you will no longer be eligible to participate in this program. You can learn more about your privacy rights at www.novonordisk-us.com/disclaimer-privacy.html.

Do you understand and agree that you are releasing only the minimally necessary information, including your first name, last name, email address, zip code, and status as a patient or caregiver (along with the other general information mentioned) to Novo Nordisk and authorized agents working on its behalf in order to assist you with enrolling for the Novo Nordisk Diabetes Savings Card?

Please make a selection.
Live Op Rep: Based on your response, you have selected that you do not Agree to releasing your personal information for the enrollment and/or activation of the Novo Nordisk Diabetes Savings Card. By not agreeing to these terms and enrollment we are unable to activate your Novo Nordisk Diabetes Savings Card. Thank you for your interest.
Items marked with (*) are required.

1.*

Before we activate your Novo Nordisk Diabetes Savings Card, we need to confirm whether the patient has insurance from any government, state, or federally funded medical or prescription benefit programs, such as, Medicare, Medigap, VA, DOD, TRICARE, Medicaid or any similar federal or state health care program. A patient who has both commercial and government funded plans is considered a patient with government insurance. Please note, the Federal Employees Health Benefits (FEHB) Program, Affordable Care (Health Exchange) Plans, and insurance provided through state employee plans are not federal or state government healthcare programs for purposes of this savings offer.

Please make a selection.
Live OP Rep: The Novo Nordisk Diabetes Savings Card is not valid for prescriptions purchased under government programs, or where prohibited by law. Thank you for calling.

2.*

Does the patient have commercial (also known as private) insurance that covers this prescription? (Example: Insurance provided through an employer)

Please make a selection.
Live OP Rep: We’re sorry, but you must be enrolled in a commercial prescription insurance plan to participate in this program. Thank you for calling.

3.*

Are you calling as the patient and affirm you are 18 years or older? Or are you calling as the Caregiver on behalf of the patient and affirm you are 18 years or older?

Please make a selection.

4.*

What is the patient's Date of Birth?

Date of birth is required.

5.*

Which medication are you looking to receive a savings card for?

Which medication are you looking to activate your savings card for?

Please make a selection.

6.*

What type of diabetes does the patient have?

Please make a selection.

7.*

How long has the patient been on this medication?”

Please make a selection.

8.*

Has the patient been on Ozempic for four weeks or less?

At this time, I just need to collect some information off your savings card in order to start the activation process.

9.*

What is the 11-digit ID number found on the front of your card?

This field is required.

The ID number entered is invalid.

Live OP Rep: If you would like to confirm and re-enter the ID, please do so now.

I am now going to ask you a few questions to complete the activation of your card.

9.*

10.*

What is the patient’s first name?

Please enter your first name.

10.*

11.*

What is the patient's last name?

Please enter your last name.

11.*

12.*

What is the patient's street address

Address is required.

12.*

13.*

What is the patient's 5-digit Zip Code

Zip code is required.

14.

15.

What is the patient’s 10-digit mobile number beginning with the area code. (It is ok if they don’t have one.)

Please read the MOBILE OPT-IN language below, word for word.

By providing your phone number, you are confirming that you would like Novo Nordisk to contact you via telephone and text message at the telephone number you provided earlier regarding Novo Nordisk’s products, goods, or services. You understand these calls or texts may be generated using an automated technology and you do not have to consent to receive communications via telephone or text messaging before purchasing goods or receiving other services from Novo Nordisk.

Do you agree with these terms?

Please make a selection.

Please read the MARKETING OPT-IN language below, word for word.

Before we complete your registration, Novo Nordisk wants to offer you an option to sign up to receive marketing communications regarding promotional or non-promotional updates via email or mail from Novo Nordisk or its partners about products, support services, or other special opportunities that Novo Nordisk or its partners believe might be interesting to you. These marketing communications are entirely optional and will in no way affect your rights related to the Novo Nordisk Diabetes Savings Card.

Novo Nordisk respects the importance of your privacy and understands your health is a very personal and sensitive subject. Novo Nordisk wants you to understand how it will use the information provided by you on this registration page. By clicking “I Agree” below, you are indicating you want to learn more about this service and receive promotional or non-promotional updates via email or mail from Novo Nordisk or its partners about products, support services, or other special opportunities that Novo Nordisk or its partners believe might be interesting to you. You also understand that you may opt out from receiving any future communications from Novo Nordisk or its partners by clicking the “unsubscribe” link within any email you receive, by calling 1.877.744.2579, or by sending us a letter containing your full contact information (e.g. name, email address, phone) to Novo Nordisk, 800 Scudders Mill Road, Plainsboro, New Jersey 08536.

To better understand how Novo Nordisk values your privacy and what other information may be collected from you while you use this service, please see our Privacy Statement at www.novonordisk-us.com.

I agree and confirm I am 18 years of age or older.

Please make a selection.

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