Program Details

NOVO NORDISK, INC.
Novo Nordisk Patient Assistance Program

Novolin R Vials (regular, human insulin injection (rDNA))
 
CONTACT INFO
Address: PO Box 370
Somerville, NJ 08876
Phone: 1-866-310-7549 Provider Phone:
Fax: 1-866-441-4190 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must not have insurance, or is enrolled in Medicare.
  • Patient cannot be enrolled in or qualify for any other federal, state, or government program such as Medicaid, Low Income Subsidy, or Veterans (VA) Benefits (with the exception of Medicare Part D).
  • Program also provides co-pay assistance.
  • Income at or below: Single 400 % FPL
      Couple 400 % FPL
    Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Medicaid denial letter
    Medicare Part D enrollees must also sign the Medicare Part D certification
    Physician License #
    Required:
    State
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment: Up to 120-day supply
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Refill Policy: A reorder form must be submitted
    Other Information:

    Last Updated: 02/08/2024


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