My insurance told me I could not get victoza anymore, it is to expensive. I just need help because it really works for me.
Novo Nordisk Patient Assistance Program
P.O. Box 181640
Louisville, KY 40261
866-310-7549 • Fax: 866-441-4190
The Novo Nordisk Patient Assistance Program provides medication to qualifying applicants at no charge. If the applicant qualifies under the
Novo Nordisk PAP guidelines, a three-month (3 month) supply of the requested medication(s) or device(s) will be shipped to the applicant’s
licensed practitioner for dispensing.
APPLYING TO THE Novo Nordisk PAP
• The applicant is required to complete sections 1.0, 1.1, 1.2, and 3.1 on the application. If you are a Medicare Part D enrollee you
must also sign and date section 3.2. Also, if you are 65 years of age or older, you must also (i) provide proof that your are not
eligible to receive Part D benefits, (ii) [provide proof that you have applied for and been denied the Low Income Subsidy (“LIS”)
from the Social Security Administration], or (iii) are enrolled in a Part D Plan and have hit the donut hole. In addition, those over
65 years of age must otherwise meet the program eligibility criteria set forth below in order to receive benefits under this
program... Please note that if you are eligible to receive the LIS, you are not eligible to receive product under the Novo Nordisk
Patient Assistance Program.
• The applicant must print his/her legal name exactly as it appears on the Social Security card issued to the applicant.
• To apply for LIS please contact the SSA at 800-772-1213 (TTY 800-325-0778) or go to www.socialsecurity.gov/prescriptionhelp/.
Attach a photocopy of LIS denial letter to the Novo Nordisk PAP application.
• Please sign the certification sections in ink.
Healthcare Practitioner Instructions:
• The prescribing licensed healthcare practitioner is required to complete sections 2.0, 2.1, and 3.0. In addition the same licensed
healthcare practitioner must complete the attached prescription sheet (Section 2.1) for a three-month supply of medication for all
products except where indicated differently.
• Please include prescription for needles when applicable
• Please sign the certification section in ink.
DOCUMENTS TO SUBMIT TO NNI PAP
• Application completed by the applicant and prescribing licensed healthcare practitioner
• Prescription for a three-month or 90-day supply of medication from the licensed healthcare practitioner who signed the
• Photocopy of applicant’s letter from a Part D Plan that applicant is not eligible to receive Part D benefits.
• Photocopy of applicant’s LIS denial letter (Medicare Part D enrollees only)
• Photocopy of documentation demonstrating that applicant has hit the donut hole (Part D enrollees only), such as an explanation
of benefits, monthly statement, or letter from Part D Plan.
• Photocopy of applicant’s most recent Federal Tax Return (1040), Social Security Income (SSA 1099), Pensions, Interest, Retirement,
Child Support, etc. (NOTE: Program will accept previous years 1040 form until May 1 of the following year; If your 1040 does not
reflect your current Income please submit two recent paystubs for all working household members)
• Patient currently receiving unemployment should submit:
o Unemployment Letter
o Last 3 months bank statements
• If patient or member of household is receiving Social Security benefits submit copy of the “Notice of Award” letter. (NOTE: If you
do not have this letter please contact your local Social Security office to request a letter stating when (date) you became eligible
for benefits and what type of benefit you are receiving.)
• Patient with zero income can submit a letter from their physician or social agency (food stamp approval) on physician or agency
Submit the completed application with photocopies of the required proof of income to FAX 866-441-4190. Faxed requests must be sent
from the healthcare practitioner’s office. Please allow up to 10 business days for processing. Applications may also be mailed to the address
above. Allow an additional 7 days for processing if mailed.
• Both the patient and healthcare practitioner will be advised in writing of approved and denied requests.
• If the applicant is approved, a three-month supply of the medication(s) or device(s) requested will be shipped to the licensed
healthcare practitioner’s office for dispensing. If you would like notification of the ship date for the requested medication, the
licensed healthcare practitioner can obtain this notification by registering for the Novo Nordisk PAP free web portal at
• All incomplete applications will be sent to either the patient or licensed healthcare practitioner with instructions for completion.
© 2010 Novo Nordisk Printed in the U.S.A. 138967-DR5 September 2010 Page 1 of 15
DPAPNNI (INSULIN) © 2010 Novo Nordisk Printed in the U.S.A. 138967-DR5 September 2010 Page 2 of 15
• Patient cannot have or qualify for Veteran’s Administration or any state or local programs.
• Patient cannot have or qualify for any private prescription coverage such as an HMO or PPO (with the exception of
Medicare Part D).
• Patient’s total household income must be at or below 200% of the Federal Poverty Level. See Chart on the following
• Patient must be a US Citizen or Legal Resident
Total Household Income
48 Contiguous States & DC
1 $21,660 $27,060 $24,920
2 $29,140 $36,420 $33,520
3 $36,620 $45,780 $42,120
4 $44,100 $55,140 $50,720
5 $51,580 $64,500 $59,320
6 $59,060 $73,860 $67,920
7 $66,540 $83,220 $76,520
8 $74,020 $92,580 $85,120
For families with more than 8 persons, add $3,740 for each additional person.
For families with more than 8 persons, add $4,680 for each additional person.
For families with more than 8 persons, add $4,300 for each additional person.
Effective date: January 23, 2009
A new application must be submitted for each new product request; provided, however that Part D beneficiaries
that have been accepted into the program need not only submit a new product request (not a new application)
every three months to receive product for the remainder of the calendar year in which they were accepted into the
program. Income documentation is only required annually.
All requests are subject to product availability and patient eligibility verification.
Novo Nordisk reserves the right to modify or cancel this program at any time without notice.
- Victoza Information for Consumers
- Victoza Information for Healthcare Professionals (includes dosage details)
- Side Effects of Victoza (detailed)
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