*What health insurance plan do you have?

 Private health insurance

 Medicaid / Medicare Part D / Medicare

 No insurance

*How do you administer your medication?
FlexPen®  Vial  Cartridge 
Policyholder Information:
Patient Information:
Male Female
Self Spouse Child Other

Prescription Insurance Information:
Formulary data are provided by Fingertip Formulary® and are current as of January 2015. Because formularies do change and many health plans offer more than one formulary, please check directly with the health plan to confirm coverage. Intended as a guide. Lower acquisition costs alone do not necessarily reflect a cost advantage in the outcome of the condition treated because there are other variables that affect relative costs. Formulary status is subject to change.