| |
Program Details
NOVO NORDISK, INC.
Novo Nordisk Patient Assistance Program
Rybelsus
(semaglutide tablet)
|
| CONTACT
INFO |
|
| Address: |
PO Box 370
Somerville, NJ 08876 |
| Phone: |
1-866-310-7549 |
Provider Phone: |
|
| Fax: |
1-866-441-4190 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
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 |
| Federal Poverty Level Calculator |
 |
| 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: |
Provider
|
| 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: 10/30/2024
|
|
Application Forms
& Instructions
The following documents
are provided in interactive PDF format, allowing you to type information
directly into the form.
 Form (English)
Form (Spanish)
|
|
