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.
Click here for a list of Novo Nordisk products covered by the PAP.
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 cannot have any private prescription coverage, such as an HMO or PPO
- Patient cannot have or qualify for:
- Department of Veterans Affairs (VA) prescription benefits
- Any federal, state, or local program such as Medicare or Medicaid. Exceptions include:
- Medicare Part D patients who have spent $1,000 on prescription medicine in the current calendar year
- Patients who are Medicare eligible and do not have Medicare Part D coverage who have applied for and been denied Extra Help/Low Income Subsidy (LIS). To apply for LIS, please contact the Social Security Administration (SSA) at 1-800-772-1213 (TTY 1-800-325-0778) or go to ssa.gov/benefits/medicare/prescriptionhelp/
- Patients who are Medicaid eligible who have applied for and been denied Medicaid
Questions?
Please call Novo Nordisk toll-free at 1-866-310-7549.
How to apply
Steps for your patient to follow:
- Download the application in English or en Español
- Complete, sign, and date the patient sections
- 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 Income Tax Return (1040)
- Social Security income, pension, and other income statements
- W-2 or 1099 form
- Unemployment benefit statement
Note: Medicare Part D patients who meet the eligibility requirements must provide photocopy documentation showing $1,000 has been spent on prescription medicine for the relevant benefit year. Acceptable documentation includes a letter from plan provider, statement, explanation of benefits (EOB), or clearly dated pharmacy printout showing amount paid by the patient for each medicine.
Steps for you as the health care professional to follow:
- Complete the “For Health Care Practitioner” section of the application
- Sign and date the application
- 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/US denial
- Applications to participate in PAP by Medicare 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 (Spanish)
PAP Refill Request Form (English)
PAP Refill Request Form (Spanish)
