NeedyMeds

This program provides brand name medications at no or low cost.

Novo Nordisk Hormone Therapy Patient Assistance Program

Provided by:

Novo Nordisk Pharmaceuticals, Inc.

PO Box 181640 Louisville, KY 40261 TEL: 866-310-7549 opt 3 ALT PHONE: FAX: 866-441-4190	Program Website

	Languages Spoken: English, Others By Translation Service

Patient assistance
applications

Medications

Activella Tablet 0.5mg/0.1mg (estradiol/norethindrone acetate)

Eligibility Requirements

APPLICATION

MEDICATION

Insurance Status	Must have no prescription coverage
Those with Part D Eligible?	No
Income	At or below 200% of FPL
Diagnosis/Medical Criteria	Not required
US Residency Required?	Yes

Obtaining	Call or download
Receiving	Faxed or mailed
Returning	Mail or fax
Doctor's Action	Complete section, sign, attach prescription
Applicant's Action	Complete section, sign, attach proof of income
Decision Communicated	Patient notified in writing
Decision Timeframe	7-10 business days

Amount/Supply	Up to 90 day supply
Sent To	Doctor's office
Delivery Time	Within 3-5 business days
Refill Process	New application
Limit	Ten months of medication for each calendar year
Re-application	New application needed for each refill

Additional Information:

Patient Assistance Program questions are provided by Cornerstones4Care.