Program Details
NOVO NORDISK, INC.
Novo Nordisk Patient Assistance Program
()
|
| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-866-310-7549 |
Provider Phone: |
|
| Fax: |
|
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Enroll Online
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 |
| Other Income
Requirements: |
Note: For Ozempic - Total household income must be at or below 200% of the Federal Poverty Level. |
| 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: |
Patient
|
| 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: 04/23/2026
www.RxAssist.org
|