LiveOp Rep: To get started, let’s check the patient’s eligibility.

* What is the patient’s first name?

Please enter the first name.

* What is the patient’s last name?

Please enter the last name.

Is the patient enrolled in insurance from any government, state, or federally funded medical or prescription benefit programs, such as, Medicare, Medigap, VA, DOD, TRICARE, Medicaid or any other state or federal medical/pharmaceutical benefit or assistance program? A patient who has both commercial and government funded plans is considered a patient with government insurance.

Yes, I have Medicare Part D

Yes, I have a Gov’t Insurance Plan, other than Medicare Part D (Medicaid, VA, DOD, Tricare, or other similar federal or healthcare program)

No, I do not have a Government provided insurance and I am not a government healthcare program beneficiary. If I should begin to receive prescription benefits under any government insurance plan, I understand that I can NO longer participate in this savings program.

Please make a selection.

Live OP Rep:No new applicants who are enrolled in any federal or state health care program with prescription drug coverage, such as Medicaid, Medicare, Medigap, VA, DOD, TRICARE, or any similar federal or state health care program (each a Government Program), are eligible to enroll in this offer.

Does the patient have Medicare Part D and were they enrolled in the Novo Nordisk My$99Insulin Program first in 2020 and re-enrolled each subsequent calendar year?

Yes, I have Medicare Part D and was enrolled in 2020 and re-enrolled each subsequent calendar year

No, I have Medicare Part D but I was not enrolled in the My$99Insulin program first in 2020.

Please make a selection.

Live OP Rep: no new applicants who are enrolled in any federal or state health care program with prescription drug coverage, such as Medicaid, Medicare, Medigap, VA, DOD, TRICARE, or any similar federal or state health care program (each a Government Program), are eligible to enroll in this offer.

Please provide your previous calendar year MyInsulinRx Program member Group Number:

Please enter Group Number

Please provide your previous calendar year My Insulin Rx Program member ID:

Please enter member ID

Live OP Rep:We’re sorry but this ID is not valid. No new applicants who are enrolled in any federal or state health care program with prescription drug coverage, such as Medicaid, Medicare, Medigap, VA, DOD, TRICARE, or any similar federal or state health care program (each a Government Program), are eligible to enroll in this offer. If you were enrolled first in 2020 and each subsequent calendar year, can you please confirm your MyInsulinRx program information with your pharmacy and call us back?

LiveOp Rep: To complete your enrollment, I just need to collect some additional information about your Medicare Part D Prescription Insurance Plan. This information will be used to notify your Medicare Part D insurer of your participation in the MyInsulinRx program. By re-enrolling in the program, you certify that you will purchase all covered insulin prescriptions before the end of this calendar year by using the My Insulin Rx offer and will not use Medicare Part D benefit, even if your benefits change.

To start, what is the patient’s Date of Birth?:

LiveOp Rep: We’re sorry but this information is needed to complete your enrollment. Please call back once you have the information available

What is the BIN Number located on your Medicare Part D Insurance Card?