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Program Details

NOVO NORDISK, INC.
Cornerstones4Care Patient Assistance Program

Levemir (insulin detemir (rDNA) injection)
 
CONTACT INFO
Address: PO Box 181640
Louisville, KY 40261
Phone: 1-866-310-7549 Provider Phone:
Fax: 1-866-441-4190 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient cannot have or qualify Veteran's Administration or any state or local programs
  • Patient cannot have or qualify for any private prescription coverage such as HMO, or PPO (with the exception of Medicare Part D).
  • The patient must have a total household income at or below 200% of the Federal Poverty Level.
  • See instructions sheet for full income guidelines.
  • Income at or below: Single 200 % FPL
      Couple 200 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
      Credit for Dependents allowed
    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
    Medicare Part D enrollees must also sign the Medicare Part D certification
    Physician License #
    Required:
    State
    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: 90 days
    Delivery Time: 0-1 week
    Re-application Policy: New financial information every 12 months
    Refill Policy: A new application is required for each refill request.
    Other Information:

    Last Updated: 04/03/2014

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)


    Document Form (Spanish)


    Document Instructions (English)


    Document Instructions (Spanish)


    Document Refill (English)


    Document Refill (Spanish)



     

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