Novo Nordisk Patient Assistance Program

Requirements for uninsured applicants

• Applicants must be at or below 400% federal poverty level to qualify
  • View federal poverty guidelines
• Application does not need hard copy, signature on application by provider is sufficient as a prescription
• Prescription information needs to be filled out for a 120 day supply
  • They do ship in 4 month supplies
• This company will not accept 4506-T form for income
• Will only send vials, This company will not send FlexPens to new applicants
• Company will send pen needles for Victoza
• This company requires the physician’s office to place the refill request for the applicants
• Applications are good for 1 year from approval date

Requirement for Medicare Part D applicants

• Medicare part D enrollees must have spent $1,000 on prescription medications year to date to qualify
• Applications for Medicare part D enrollees are valid until December 31st of current year