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Urgent Needs State Insulin Program

My pharmacy is located in:

^* Location

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)

I certify, by checking and submitting this page I have received a completed state application from the patient and will dispense a Biocon Biologics insulin product to the eligible patient in accordance with the applicable State Insulin Safety Net/Affordability Program. In addition, I certify that I will comply with the requirements of the applicable State Insulin Safety Net/Affordability Program, including, without limitation, that I will not seek any reimbursement from any third party payer for the Biocon Biologics insulin product, except for the manufacturer voucher available under the Biocon Biologics Insulin State Urgent Need Safety Net/Affordability Program.*

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