Minnesota Continuing Need Insulin Safety Net Program

Eligibility Requirements:

• Patient must be a resident of Minnesota and can provide one of the following:
  • Valid Minnesota driver’s license
  • Valid Minnesota identification card
  • Valid tribal identification card from a Minnesota tribe
  • If the person who needs insulin is under the age of 18, the parent or legal guardian must provide proof of residency
• Patient is not enrolled in Medical Assistance or MinnesotaCare
• Patient (if eligible) has applied for and has been denied Medicaid and/or Medicare Extra Help/LIS
• Patient’s total household income is at or below 400% of the federal poverty level (FPL)
• Patient is not eligible to receive health care benefits through federally funded programs, with the exception of Medicare
• Patient is not enrolled or eligible to receive prescription drug benefits through the Department of Veterans Affairs
• If the patient has private prescription drug coverage, their out-of-pocket cost for a 30-day supply of insulin is greater than $75

How to apply:

1. Instruct patient to download and complete application
   • Be sure to sign and date as required
   • Be sure all sections are complete and accurate
2. Gather required documentation
   • Copy of proof of income
   • Copy of Minnesota ID
3. As the health care provider, complete HCP section of application, sign and date, and then fax or mail the completed application, proof of income, and proof of residency to 1-866-441-4190, or mail them to Novo Nordisk Inc., PO Box 370 Somerville, NJ 08876
4. Patients and prescribers will be notified of the decision by mail
5. If approved, a 120-day supply of insulin will be shipped directly to the patient's residence as listed on the application. Someone will reach out to the patient directly to schedule a time for delivery