Save on Xultophy® 100/3.6

Pay as little as $1 per day, if eligiblea

With the Xultophy® 100/3.6 Savings Card, you pay as little as $1 per day on plans that cover Xultophy® 100/3.6 and receive a FREE box of Novo Nordisk needles.b You will also be enrolled in the patient support program for Xultophy® 100/3.6 at no cost to you.

aMaximum savings of $400 per month, up to 12 months. Eligibility and other restrictions apply.
bNeedles may require a prescription in some states. 

Request or activate your Xultophy® Savings Card

*Required fields

Some error has occurred. Please try again. User already exists. We're sorry, your account is currently unavailable. We're currently working to fix the issue. Please check back soon.
  • Enter the 9-digit number on the front of the card:
Please enter your 9 digit card number.
Please select one item.
  • Please enter your first name.
    Please enter a valid first name.
  • Please enter your last name.
    Please enter a valid last name.
  • Please enter your date of birth.
    Please enter patient's date of birth.
    {{registerModel.dob_error}}
    Please enter a valid date of birth.
    Patients under 18 years old cannot register.
    Patients under 18 years old cannot register.

By checking this box, I certify that I am the parent or legal guardian of a child under 18 years old with diabetes.

Required Required
  • Please enter a password.
    Please enter a valid password that contains at least 8 characters, with at least 1 number, 1 lowercase letter, and 1 uppercase letter.
    Must be 8 characters or more and contain at least 1 capital letter, 1 lowercase letter, and 1 number.
  • Please enter a matching password.
    Please enter a matching password.
Please enter a security answer.
Please enter a security answer.
 
  • Please enter a street address.
    Please enter a valid street address.
  • Please enter a city.
    Please enter a valid city.
  • Please select a state.
  • Please enter a zip code.
    Please enter a valid zip code.
  • {{registerModel.patient_dob_error}}

  • Please enter a phone number.
    Please enter a valid phone number.
    By providing your phone number and checking the box below, you agree to receive calls from a diabetes educator.
  • By providing your mobile number and checking the box below, you agree to receive calls and texts from a diabetes educator.

Why do you need my information?

The more we know about you and your diabetes, the better we can personalize your Cornerstones4Care® experience.

Maintaining your privacy is important to you. And it’s important to us, too. Please read our Privacy Policy to learn more about how we protect your personal information.

To register by phone, please call 1‑866‑696‑4084.

 

Yes, I’d like to be contacted by Novo Nordisk via phone calls and text messages at the phone number I have provided. By checking this box, checking the “I Agree” box below, and clicking "Submit." I authorize Novo Nordisk to use auto-dialers, prerecorded messages, and artificial voice messages to contact me. I understand that these calls and text messages may market or advertise Novo Nordisk products, goods, or services. I understand that I am not required to consent to being contacted by phone or text message as a condition of any purchase of goods or services.

I may opt out at any time by clicking the unsubscribe link within any email I receive, by calling 1-877-744-2579, or by sending a letter with my request to Novo Nordisk Inc., 800 Scudders Mill Road, Plainsboro, New Jersey 08536.

*Are you enrolled in any government, state, or federally funded medical or prescription benefit programs? This includes Medicare, Medicaid, Medigap, VA, DOD, and TRICARE, or any similar federal or state health care program. For purposes of this savings program, the Federal Employee Health Benefits (FEHB) Program is not a federal or state government health care program.

You are not eligible to participate in this program because you currently participate in a government, state, or federally funded prescription benefit program.
Please select an answer.
Please select an answer.

*Do you have commercial (also known as private) insurance that covers your prescription? (Example: Insurance provided through an employer)

You are not eligible to participate in this program because you currently do not have commercial (also known as private) insurance that covers your prescription.
Please select an answer.
Please select an answer.

*The Savings Card is not valid for prescriptions purchased under Medicaid, Medicare, or similar federal, state, or government-funded benefit programs. The federal employee health benefits program is not a federal or state government health care program for purposes of this savings program. If eligible, I understand that certain information pertaining to my use of the Card will be shared by my pharmacy with Novo Nordisk, the sponsor of the Card. The information disclosed will include the date I filled the prescription, amount of medication dispensed by my pharmacist, and amount I will be reimbursed by Novo Nordisk. This information may be used by Novo Nordisk to provide me with information about my prescription. Should I begin receiving prescription benefits from a federal, state, or other government-funded program at any time, I will no longer be eligible to participate in this program. You may contact me by phone or mail periodically in order to verify that my eligibility for the program has not changed.

Please select an answer.
Please select an answer.

Novo Nordisk Inc. (“Novo Nordisk”) understands protecting your personal and health information is very important. We do not share any personally identifiable or health information you give us with third parties for their own marketing use.

I understand from time to time Novo Nordisk’s Privacy Policy may change, and for the most recent version of the Privacy Policy, I should click here.

By checking “I Agree” and clicking “Submit,” I consent that the information I am providing may be used by Novo Nordisk, its affiliates, or vendors to keep me informed about products, patient support services, special offers, or other opportunities that may be of interest to me via mail or email. These materials may contain information that markets or advertises Novo Nordisk products, goods, or services. Novo Nordisk may also combine the information I provide with information about me from third parties to better match these offers with my interests.

You must check the "I Agree" box and click "Submit" to complete your registration. If you do not agree to the terms above, you may exit out of this page and we invite you to explore other areas of the site without registering. You may return to this page at any time to register. You must check the "I Agree" box and click "Submit" to complete your registration. If you do not agree to the terms above, you may exit out of this page and we invite you to explore other areas of the site without registering. You may return to this page at any time to register.
Some error has occurred. Please try again. User already exists. We're sorry, your account is currently unavailable. We're currently working to fix the issue. Please check back soon. {{registerModel.webserviceError}}
Please enter all required fields.


Trouble registering? Contact us to get support.