Ozempic Patient Assistance Form
The Novo Nordisk Patient Assistance Program (PAP) provides medication at no charge to applicants who qualify under the PAP guidelines. Requested medications or devices are shipped to a licensed health care professional for dispensing, up to a 120-day supply.
The Novo Nordisk PAP is free. There is no registration charge or monthly fee for participating in the Novo Nordisk PAP. All requests are subject to product availability and patient eligibility verification. Product is provided at no cost to the patient or the HCP, is not contingent on any product purchase, and the patient and HCP agree to not bill any third party for the product nor resell the product.
Patient eligibility
- You must be a US citizen or legal resident
- Your total household income must be at or below 400% of the federal poverty level (FPL). Visit the NeedyMeds Website at https://www.needymeds.org/poverty-guidelinespercents/, which lists the current FPL guidelines
- You cannot have any private prescription coverage, such as an HMO or PPO
- You cannot have or qualify for: – Department of Veterans Affairs (VA) prescription benefits – Any federal, state, or local program such as Medicare or Medicaid
- Exceptions include: –
- Medicare Part D patients who have spent $1,000 on prescription medicine in the current calendar year –
- Patients who are Medicare eligible and do not have Medicare Part D coverage and who have applied for and been denied Extra Help/Low Income Subsidy (LIS) To apply for LIS, please contact the Social Security Administration (SSA) at 800-772-1213 (TTY 800-325-0778) or go to www.ssa.gov/benefits/medicare/prescriptionhelp/ – Patients who are Medicaid eligible who have applied for and been denied Medicaid