Patient Assistance Program- Diabetes Care

The Novo Nordisk Patient Assistance Program (PAP) is based on our commitment to people living with diabetes and on our philosophy, known as the Novo Nordisk Triple Bottom Line. The Novo Nordisk PAP provides free diabetes medicine to those who qualify.

If you are approved, a free 120-day supply of medicine is sent to the prescribing health care provider's office. Once we have your prescription, your doctor will receive a reorder reminder from Novo Nordisk every 3 months. After your doctor places a reorder, your medicine will be sent to your doctor’s office.

Do you qualify for PAP?

You are eligible if:

  • You are a US citizen or legal resident
  • Your total household income is at or below 200% of the federal poverty level (FPL). See the chart on the PAP Application (in English or Spanish) or visit the Families USA Web site, which lists the 2014 FPL guidelines.

You are not eligible if you have:

  • Any private prescription coverage, such as an HMO or PPO
  • Any federal, state, or local program, such as Medicare or Medicaid. Exceptions include patients who have entered the coverage gap (donut hole) in
    Medicare Part D, and patients who have applied for and been denied Medicare Extra Help/Low Income Subsidy (LIS) and are Medicare eligible
  • Department of Veterans Affairs (VA) prescription benefits

Program participants agree to verification of eligibility. Participants who are eligible for Medicaid must provide proof of Medicaid denial.

Simple steps for a free 120-day supply of medicine

If you qualify for PAP, please follow these easy steps:

  • Download the Application (in English or Spanish)
  • Complete the "For Patient," "Patient Signature," and "Date" sections on the Application
  • Make copies of your proof of income
    • Your most recent federal income tax return (Form 1040)
    • Social Security Form SSA-1099
    • Form W-2
    • Pay stubs from the last month
  • Take the application and proof of income to your doctor

Your doctor must do the following:

  • Complete the "For Health Care Practitioner" section of your application
  • Sign and date your application
  • Fax the completed application and your proof of income to Novo Nordisk Patient Assistance at (866) 441-4190. (Important: Faxes must be sent from your doctor’s office.)
  • You can also mail the completed application, proof of income, and order information to:
    Novo Nordisk Inc.
    P.O. Box 370
    Somerville, NJ 08876

Please allow up to 10 business days for processing.

That’s it! After your application is reviewed, you will be informed of the decision. Your doctor will be notified as well. If approved, your medicine will be sent to your doctor’s office, where you can pick it up.

Once we have your prescription, your doctor will receive a reorder reminder every 3 months. After your doctor places a reorder, your medicine will be sent to your doctor’s office.

A new application must be submitted for each new product request.

You can renew each year for as long as you qualify. Your renewal is valid for 12 months.

Download an Application Form (in English or Spanish)

Download a Refill Request Form (in English or Spanish)

View products covered by PAP

Novo Nordisk reserves the right to modify or cancel this program at any time without notice.

Downloadable PDF:
PAP Application Forms

English
Spanish

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Downloadable PDF:
PAP Refill Request Forms

English
Spanish

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Downloadable PDF:
Products covered by PAP

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