Patient Assistance Program

The Novo Nordisk Patient Assistance Program (PAP) is based on our commitment to people living with diabetes. The Novo Nordisk PAP provides medication at no cost to those who qualify. There is no registration charge or monthly fee for participating.

Click here for a list of Novo Nordisk products covered by the PAP.

Patient Assistance Program

The Novo Nordisk Patient Assistance Program (PAP) is based on our commitment to people living with diabetes. The Novo Nordisk PAP provides medication at no cost to those who qualify. There is no registration charge or monthly fee for participating.

Click here for a list of Novo Nordisk products covered by the PAP.

If you have a patient who has lost health insurance coverage because of a change in job status due to COVID-19, they may be eligible for a free 90-day supply of insulin. See required documentation below.

See if a patient qualifies for the PAP

Eligibility requirements:

  • Patient must be a US citizen or legal resident
  • Total household income must be at or below 400% of the federal poverty level (FPL). Visit the NeedyMeds website, which lists the current FPL guidelines
  • Patient has no insurance or has Medicare
  • Patient is not enrolled in and doesn't qualify for any other federal, state, or government program such as Medicaid, Low Income Subsidy, or Veterans (VA) Benefits
    • Exceptions include patients who are Medicaid eligible who have applied for and been denied Medicaid
  • See eligibility requirements for Minnesota residents

Documentation required for patients affected by COVID-19:

  • Completed PAP application
  • Documentation showing loss of healthcare benefits (job termination notice, job status change, proof of COBRA benefits being offered)
  • No proof of income required

If approved, your patient will receive a free 90-day supply of insulin. Novo Nordisk will check back with them (before their 90-day enrollment ends) to determine continued eligibility. Assistance can be extended to the end of 2020 for otherwise eligible patients who have been denied Medicaid coverage.

Questions?

Please call Novo Nordisk toll-free at 1-866-310-7549.

How to apply

Steps for your patient to follow:

  1. Download the application in English or en Español
  2. Complete, sign, and date the patient sections
  3. Make a copy of one of the following items to show adjusted gross annual household income: 
    • 2 most current paycheck stubs or earning statements for all working members in the household
    • Last year’s federal Individual Income Tax Return (1040)
    • Social Security income, pension, and other income statements
    • W-2 or 1099 form
    • Unemployment benefit statement

Steps for you as the health care professional to follow:

  1. Complete the “For Health Care Practitioner” section of the application
  2. Sign and date the application
  3. Fax the completed application and proof of income to 1-866-441-4190, or mail them to Novo Nordisk Inc., PO Box 370, Somerville, NJ 08876. (Important: Faxes must be sent from your office.)

Reminders:

  • Do not include medical records with this application
  • Patients who are eligible for Medicaid must complete the Medicaid Eligibility form (proof of denial must be submitted if requested at any time) 
  • Patients who are eligible for Medicare Part D must provide proof of Medicaid or Extra Help/LIS denial
  • Applications to participate in PAP by Medicare enrollees must be submitted by November 30th of each calendar year

After the application is reviewed, you and your patient will be informed of the decision. If approved, an initial 120-day supply of medicine will be sent to your office, where your patient can pick it up. Please allow up to 10 business days for processing.

Click here for a full list of available products.

How to renew your patient's prescription

You will receive a reorder reminder from Novo Nordisk before your patient is due for a refill. You will need to place a reorder during the calendar year for which your patient has been approved to receive medicine. Reorders can be requested by completing and submitting the Refill Request Form below or by calling Novo Nordisk toll-free at 1-866-310-7549.

Patients can renew each year for as long as they qualify. For uninsured patients, an approved application is valid for 12 months. For patients with Medicare Part D coverage, an approved application is valid for the benefit year only. Some restrictions may apply.

Novo Nordisk reserves the right to modify or cancel this program at any time without notice.

Patient Assistance Program Forms

PAP Application Form (English)

 

PAP Application Form (Español)

 

PAP Refill Request Form (English)

 

PAP Refill Request Form (Español)

 

Connect patients to low-cost insulin options

Learn about low-cost insulin options that may be more affordable, especially for those without insurance or with high-deductible health insurance plans.

Patients can get help with diabetes management

Help patients discover tools and resources tailored to their needs at Cornerstones4Care.com.

NovoCare® is a registered trademark of Novo Nordisk A/S.
Novo Nordisk is a registered trademark of Novo Nordisk A/S.
All other trademarks, registered or unregistered, are the property of their respective owners.

© 2020 Novo Nordisk  All rights reserved. US20NC00067  October 2020