Patient Assistance Program
The Novo Nordisk Patient Assistance Program (PAP) is based on our commitment to people living with hemophilia and rare bleeding disorders. This program provides medication at no cost to those who qualify.
If approved, you may qualify to receive free hemophilia and rare bleeding disorder medicine from Novo Nordisk. There is no registration charge or monthly fee for participating.
Patient Assistance Program
The Novo Nordisk Patient Assistance Program (PAP) is based on our commitment to people living with hemophilia and rare bleeding disorders. This program provides medication at no cost to those who qualify.
If approved, you may qualify to receive free hemophilia and rare bleeding disorder medicine from Novo Nordisk. There is no registration charge or monthly fee for participating.
See if you qualify
for the PAP
Eligibility requirements:
- I am a US citizen or legal resident
- My total household income is at or below 400% of the federal poverty level (FPL). Visit the NeedyMeds website, which lists the current FPL guidelines
- I do not have prescription coverage, such as an HMO or PPO, and I do not qualify for any other federal, state, or government program such as Medicare or Medicaid
- Patients who are eligible for Medicaid or Department of Veterans Affairs (VA) prescription benefits must have been denied enrollment, including exhaustion of all appeals, in order to be eligible for the PAP
- Patients who are Medicare eligible but do not have Medicare Part D coverage must have applied for and been denied the Low Income Subsidy (LIS) from the Social Security Administration (SSA). To apply for LIS, please contact the SSA at 1-800-772-1213 (TTY 1-800-325-0778) or go to the SSA
- I have been prescribed a Novo Nordisk factor product for an indicated condition
Questions? Please call Novo Nordisk toll-free at 1-844-668-6732.
How to apply
in 3 steps
STEP 1
Download and fill out the application
- Complete the following sections:
- Patient information
- Patient certification and authorization
STEP 2
Gather the required documents
- Proof of income is needed. Make a copy of one of the following items to show your adjusted gross annual income:
- 2 most current paycheck stubs or earning statements for all working members of your household
- Last year’s federal income tax return (1040)
- Social Security income, pension, and other income statements, including interest of dividend statements
- Last year’s (or most current) W-2 or 1099 form
- Unemployment benefits statement
- Medicaid, Veterans Affairs, or Extra help/LIS denial letter (as appropriate, denial letters must be provided with the application and be dated within 1 year of applying for the PAP)
- Prescription with exact quantity and assay limits
Important: Do not include medical records with this application
New and annual renewal applications without proof of income documentation are considered incomplete.
STEP 3
Take the application and required documents to your health care provider
- Your health care provider must:
- Complete the Provider information section of the application
- Sign and date the application
- Fax all required documents to 1-866-488-6576, mail them to NovoSecure™, PO Box 18648, Louisville, KY 40261-9961, or scan and email them to MyNovoSecureSupervisor@MyNovoSecure.com
Please allow up to 10 business days for processing.
See if you qualify for the PAP
Eiligibilty requirements:
- I am a US citizen or legal resident
- My total household income is at or below 400% of the federal poverty level (FPL). Visit the NeedyMeds website, which lists the current FPL guidelines
- I do not have prescription coverage, such as an HMO or PPO, and I do not qualify for any other federal, state, or government program such as Medicare or Medicaid
- Patients who are eligible for Medicaid or Department of Veterans Affairs (VA) prescription benefits must have been denied enrollment, including exhaustion of all appeals, in order to be eligible for the PAP
- Patients who are Medicare eligible but do not have Medicare Part D coverage must have applied for and been denied the Low Income Subsidy (LIS) from the Social Security Administration (SSA). To apply for LIS, please contact the SSA at 1-800-772-1213 (TTY 1-800-325-0778) or go to the SSA
- I have been prescribed a Novo Nordisk factor product for an indicated condition
Questions?
Please call Novo Nordisk toll-free at 1-844-668-6732.
How to apply in 3 steps
STEP 1
Download and fill out the application
- Complete the following sections:
- Patient information
- Patient certification and authorization
STEP 2
Gather the required documents
- Proof of income is needed. Make a copy of one of the following items to show your adjusted gross annual income:
- 2 most current paycheck stubs or earning statements for all working members of your household
- Last year’s federal income tax return (1040)
- Social Security income, pension, and other income statements, including interest of dividend statements
- Last year’s (or most current) W-2 or 1099 form
- Unemployment benefits statement
- Medicaid, Veterans Affairs, or Extra help/LIS denial letter (as appropriate, denial letters must be provided with the application and be dated within 1 year of applying for the PAP)
- Prescription with exact quantity and assay limits
Important: Do not include medical records with this application
New and annual renewal applications without proof of income documentation are considered incomplete.
STEP 3
Take the application and required documents to your health care provider
- Your health care provider must:
- Complete the Provider information section of the application
- Sign and date the application
- Fax all required documents to 1-866-488-6576, mail them to NovoSecure™, PO Box 18648, Louisville, KY 40261-9961, or scan and email them to MyNovoSecureSupervisor@
MyNovoSecure.com
Please allow up to 10 business days for processing.
Safe disposal program
It’s important to properly dispose of your used Novo Nordisk products.
Safe disposal program
It’s important to properly dispose of your used Novo Nordisk products.
Safe disposal program
It’s important to properly dispose of your used Novo Nordisk products.
