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Home » Patient Assistant Program

Patient Assistant Program

1. AZ & ME (AstraZeneca Program)
Click here to view the list of medications covered under the AZ & ME program.

2. Novo NorDisk Application (English, Español)

3. Amerigroup Value Add Service

How to Apply

Download and fill out the application

  • Complete the following sections:
    • Part 2: Patient Information
    • Part 3: Patient Certification and Authorization

Gather proof of income

  • Make a copy of one of the following items to show your adjusted gross annual household income:
    • 2 most current paycheck stubs or earning statements for all working members of your household
    • Last year’s federal Individual Income Tax Return (1040)
    • Social Security income, pension, and other income statements
    • W-2 or 1099 forms
    • Unemployment benefit statements

Take the application and proof of income to your health care provider

  • Your health care provider must:
    • Complete the “For Health Care Practitioner” section of the application, including “Order information” (subsection D)
    • Sign and date the application
    • Fax the completed application and proof of income to 1-866-441-4190, or mail them to Novo Nordisk Inc., PO Box 370, Somerville, NJ 08876. Faxes must be sent from your health care provider’s office