Xultophy® 100/3.6 Savings Card

Details of Offer Including Restrictions on Eligibility and Other Limitations

By participating in the Xultophy® 100/3.6 Savings Card Program, participants understand and agree that the information provided, as well as the information obtained about them from the pharmacy, will be shared with the manufacturer and any companies working with the manufacturer. Participants also affirm that they will not submit, and have not had submitted on their behalf, a claim for reimbursement or coverage for items purchased with this card under Medicaid, Medicare, TRICARE, or any other federal or state government health care program, or where prohibited by state law.

Program terms and conditions:
  • Pay as little as $30 out of pocket. Novo Nordisk will pay up to $400 of your co-pay for each of your first 12 prescription fills for 1 year from the time of initial card activation. Eligibility and other restrictions apply. Novo Nordisk reserves the right to modify or cancel this program at any time. If your co-pay is already $30 or less, this offer does not apply.
  • Offer not valid for prescriptions paid in part or full by any federally or state-funded programs, including but not limited to Medicare or Medicaid, Medigap, VA, DOD, TRICARE, and where prohibited by law. The Federal Employee Health Benefits Program is not a federal or state government health care program for purposes of this savings program    
  • You must have a co-payment. Not valid for full cash payments for your prescriptions
  • Offer good only in the USA at participating retail pharmacies and cannot be redeemed at government-subsidized clinics. Void where taxed, restricted, or prohibited by law
  • Offer not extended to clubs, groups, or organizations
  • Participation in this program must comply with all applicable laws and contractual or other obligations as a pharmacy provider
  • This is not an insurance program
  • Participating patients and pharmacists understand and agree to comply with the terms and conditions of this offer as set forth herein
  • Participating patients must re-present their Xultophy® 100/3.6 Savings Card if changing pharmacies
  • Any step edits or prior authorizations required by the insurance plan still apply
  • The Xultophy® 100/3.6 Savings Card may be used for mail order. This card is not transferable
  • This offer is limited to 1 card per patient
  • Novo Nordisk reserves the right to modify or cancel this program at any time