Insulin State Urgent Need Program


My pharmacy is located in:



Colorado


Pursuant to Colorado law, to be eligible for this program and receive a 30-day urgent-need supply of insulin, the patient must:

  • Be a resident of Colorado
  • Have a current prescription for insulin
  • Have an emergency need for insulin
  • Have less than a 7-day supply of insulin available
  • Pay more than $100 for a 30-day supply for the patient's insulin
  • Present identification proving Colorado residency including, but not limited to, a valid Colorado identification card, driver's license or permit, or tribal-issued identification. If the patient is a minor under the age of 18, the patient's parent or legal guardian must provide proof of residency

Colorado State Insulin Affordability Program application (to be completed by patient)

Maine


Pursuant to Maine law, to be eligible for this program and receive an 30-day urgent-need supply of insulin, the patient must:

  • Be a resident of Maine
  • Have a valid insulin prescription
  • Have an urgent need of insulin ("urgent need of insulin" means having readily available for use less than a 7-day supply of insulin and in need of insulin in order to avoid the likelihood of suffering significant health consequences)
  • Not be enrolled in MaineCare
  • Not be enrolled in any other health coverage or prescription drug coverage that limits the total amount of cost-sharing that the enrollee is required to pay for a 30-day supply of insulin, including co-payments, deductibles, or coinsurance, to $75 or less, regardless of the type or amount of insulin prescribed
  • Not have received an urgent-need supply of insulin through this program within the previous 12 months (unless authorized under Maine law )
  • Present valid identification indicating residency in the form of a valid Maine identification card, driver's license or permit to the pharmacy. If the patient in urgent need of insulin is under the age of 18, the patient's parent or legal guardian must provide the pharmacy with proof of residency

Patient can normally access an urgent-need insulin supply only once in a 12-month period. However, if patient is waiting for MaineCare coverage to begin, or if patient has been determined ineligible for a manufacturer's patient assistance program by the manufacturer and is waiting for the Maine Board of Pharmacy's decision on an appeal, patient may be eligible to access a second 30-day supply


Maine State Insulin Safety Net Program Application (to be completed by patient)

Minnesota


Pursuant to Minnesota law, to be eligible for this program and receive an urgent-need 30-day supply of insulin, the patient must:

  • Live in Minnesota
  • Have an urgent need of insulin ("urgent need of insulin" means having readily available for use less than a 7-day supply of insulin and in need of insulin in order to avoid the likelihood of suffering significant health consequences)
  • Have a current prescription for insulin
  • Pay more than $75 each month for insulin
  • Not be enrolled in Medical Assistance or MinnesotaCare
  • Present identification proving Minnesota residency in the form of a valid Minnesota identification card, driver's license or permit, or tribal-issued identification. If the patient is a minor under the age of 18, the patient's parent or legal guardian must provide the pharmacy with proof of residency

Patient can normally access an urgent-need insulin supply only once in a 12-month period. However, if patient is waiting for Medical Assistance or MinnesotaCare coverage to begin, or if patient has been determined ineligible for a manufacturer's patient assistance program by the manufacturer and are waiting for the Minnesota Board of Pharmacy's decision on an appeal, patient may be eligible to access a second 30-day supply.


Minnesota State Insulin Safety Net Program application (to be completed by patient)

*Required