Please see the following pages for Tresiba®,

Xultophy® 100/3.6, and Fiasp® Dosing, 1

INSULIN-CONTAINING PRODUCTS FROM NOVO NORDISK Storage, and Savings Information.
BASAL

100 units/mL; total of 200 units/mL; total of 100 units/mL; total of

300 units/pen; 5-pen pack1 600 units/pen; 3-pen pack1 1000 units/vial; 1 vial/pack1
NDC: 0169-2660-15 NDC: 0169-2550-13 NDC: 0169-2662-11
BASAL/GLP-1 RA

100 units/mL insulin degludec and 3.6 mg/mL liraglutide;

total of 300 units insulin degludec and 10.8 mg liraglutide; 5-pen pack2
NDC: 0169-2911-15

Approved for use in pumps3

PRANDIAL

Refer to the insulin infusion pump user manual

to see if Fiasp® can be used. Use in accordance
with the insulin pump’s Instructions for Use.
100 units/mL; total of 300 units; 100 units/mL; total of 100 units/mL; total of
5-pen pack3 300 units/pen; 5-cartridge pack3 1000 units/vial; 1 vial/pack3
NDC: 0169-3204-15 NDC: 0169-3205-15 NDC: 0169-3201-11

GLP-1 RA=glucagon-like peptide-1 receptor agonist.

Tresiba® Indications and Usage Xultophy® 100/3.6 Indications and Xultophy® 100/3.6 Important Safety Fiasp® Indications and Usage
Tresiba® (insulin degludec injection) is indicated to Limitations of Use Information Fiasp® (insulin aspart injection) 100 U/mL is a
improve glycemic control in patients 1 year of age and Xultophy® 100/3.6 (insulin degludec and liraglutide injection) rapid-acting insulin analog indicated to improve
older with diabetes mellitus. WARNING: RISK OF THYROID C-CELL TUMORS
100 units/mL and 3.6 mg/mL is a combination of insulin glycemic control in adult and pediatric patients with
• L iraglutide, one of the components of Xultophy® 100/3.6, causes
degludec and liraglutide and is indicated as an adjunct to diet diabetes mellitus.
Limitations of Use and exercise to improve glycemic control in adults with type 2
dose-dependent and treatment-duration-dependent thyroid
Tresiba® is not recommended for treating diabetic C-cell tumors at clinically relevant exposures in both genders of
ketoacidosis.
diabetes mellitus. rats and mice. It is unknown whether Xultophy® 100/3.6 causes Fiasp® Important Safety Information
• Xultophy® 100/3.6 is not recommended as first-line therapy thyroid C-cell tumors, including medullary thyroid carcinoma
for patients who have inadequate glycemic control on diet (MTC), in humans, as the human relevance of liraglutide-induced Contraindications
Tresiba® Important Safety and exercise. rodent thyroid C-cell tumors has not been determined. • Fiasp® is contraindicated during episodes of
Information • Xultophy® 100/3.6 is not recommended for use in combination • Xultophy® 100/3.6 is contraindicated in patients with a personal hypoglycemia and in patients hypersensitive to
with any other product containing liraglutide or another GLP-1 or family history of MTC and in patients with Multiple Endocrine Fiasp® or one of its excipients.
Contraindications receptor agonist (GLP-1 RA). Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding
• Xultophy® 100/3.6 is not indicated for use in patients with type 1 the potential risk for MTC with the use of Xultophy® 100/3.6
• Tresiba® is contraindicated during episodes of and inform them of symptoms of thyroid tumors (e.g. a mass in
hypoglycemia and in patients with hypersensitivity to diabetes mellitus or for the treatment of diabetic ketoacidosis.
• Xultophy® 100/3.6 has not been studied in combination with the neck, dysphagia, dyspnea, persistent hoarseness). Routine
Tresiba® or one of its excipients monitoring of serum calcitonin or using thyroid ultrasound is of
prandial insulin.
uncertain value for early detection of MTC in patients treated
with Xultophy® 100/3.6.
Click here for Prescribing Information for Tresiba®.
Click here for Prescribing Information, including Boxed Warning, for Xultophy® 100/3.6.
Click here for Prescribing Information for Fiasp®.
Please see additional Important Safety Information for Tresiba®, Xultophy® 100/3.6, and Fiasp® throughout.
 2
INDICATION MAX DOSE PER INJECTION STARTING DOSE

A long-acting human insulin analog U-100 pen: 80 units; 1-unit dose increments T1D insulin naïve1: Approximately one-third
BASAL

indicated to improve glycemic control to one-half of the total daily insulin dose
U-200 pen: 160 units; 2-unit increments
in patients 1 year of age and older with
diabetes mellitus.1 U-100 vial: N/A; allows for half-unit dosing T2D insulin naïve1: 10 units QD
BASAL/GLP-1 RA

A combination of insulin degludec, a

long-acting human insulin analog, and
liraglutide, a GLP-1 RA, indicated as an Naïve to basal insulin or a
50 units; 1-unit dose increments
adjunct to diet and exercise to improve GLP-1 RA2: 10 units QD
glycemic control in adults with
type 2 diabetes mellitus.2

3-mL pen: 80 units; 1-unit dose increments Individualize dosage based on patients’
PRANDIAL

A rapid-acting human insulin analog 3-mL PenFill®: N/A; allows for half-unit dosing metabolic needs, blood glucose monitoring
indicated to improve glycemic control results, and glycemic control goal3
in adult and pediatric patients with U-100 vial: N/A; allows for half-unit dosing
diabetes mellitus.3 Administer at the start of the meal OR within
PenFill® cartridges are designed for use with
20 minutes after starting a meal
Novo Nordisk insulin delivery devices

T1D=type 1 diabetes; T2D=type 2 diabetes; QD=once daily.

Tresiba® Important Safety Information (cont’d) Xultophy® 100/3.6 Important Safety Information Fiasp® Important Safety Information (cont’d)
Warnings and Precautions
(cont’d) Warnings and Precautions
•N
 ever Share a Tresiba® FlexTouch® Pen, Needle, or Syringe Contraindications • Never share a Fiasp® FlexTouch® Pen, PenFill® cartridge or PenFill®
Between Patients, even if the needle is changed. Patients using • Xultophy® 100/3.6 is contraindicated during episodes of hypoglycemia and cartridge device between patients, even if the needle is changed.
Tresiba® vials should never share needles or syringes with another person. in patients with hypersensitivity to Xultophy® 100/3.6, either of the active Patients using Fiasp® vials must never share needles or syringes with another
Sharing poses a risk for transmission of blood-borne pathogens substances, or any of its excipients. Serious hypersensitivity reactions including person. Sharing poses a risk for transmission of blood-borne pathogens.
•H
 yperglycemia or Hypoglycemia with Changes in Insulin Regimen: anaphylactic reactions and angioedema have been reported with liraglutide, one •H yperglycemia or Hypoglycemia with Changes in Insulin
Changes in an insulin regimen (e.g., insulin strength, manufacturer, type, or of the components of Xultophy® 100/3.6. Regimen: Changes in an insulin regimen (e.g., insulin strength,
injection site or method of administration) may affect glycemic control and manufacturer, type, injection site or method of administration) may affect
predispose to hypoglycemia or hyperglycemia. Repeated insulin injections into Warnings and Precautions glycemic control and predispose to hypoglycemia or hyperglycemia.
areas of lipodystrophy or localized cutaneous amyloidosis have been reported •R
 isk of Thyroid C-cell Tumors: If serum calcitonin is measured and found to be Repeated insulin injections into areas of lipodystrophy or localized
to result in hyperglycemia; and a sudden change in the injection site (to an elevated or thyroid nodules are noted on physical examination or neck imaging, cutaneous amyloidosis have been reported to result in hyperglycemia; and
unaffected area) has been reported to result in hypoglycemia. Make any changes the patient should be further evaluated. a sudden change in the injection site (to an unaffected area) has been
to a patient’s insulin regimen under close medical supervision with increased reported to result in hypoglycemia. Make any changes to a patient’s insulin
frequency of blood glucose monitoring. Advise patients who have repeatedly regimen under close medical supervision with increased frequency of blood
injected into areas of lipodystrophy or localized cutaneous amyloidosis to change glucose monitoring. Advise patients who have repeatedly injected into
the injection site to unaffected areas and closely monitor for hypoglycemia. areas of lipodystrophy or localized cutaneous amyloidosis to change the
Adjustments in concomitant anti-diabetic treatment may be needed. injection site to unaffected areas and closely monitor
Click here for Prescribing Information for Tresiba®. for hypoglycemia. Adjustments in concomitant
anti-diabetic treatment may be needed.
Click here for Prescribing Information, including Boxed Warning, for Xultophy® 100/3.6.
Click here for Prescribing Information for Fiasp®.
Please see additional Important Safety Information for Tresiba®, Xultophy® 100/3.6, and Fiasp® throughout.
 3
DOSING CONVERSION STORAGE SAVINGS CARD INFORMATIONa,b

RESIBA S LITTLE
YA
Tresiba® Instant Savings
T
PAY NO Card
®

AS
PA
MORE THAN
$
To activate your card, call
$
15

Y
PE

PL
Adults with T1D or T2D : Unopened : Refrigerate (36°F-46°F)
30
-DAY S UP
1-877-304-6852

R
1 1 or visit SaveOnTresiba.com

el
Pe
• Pay as little as $5 per 30-day supply for up to 24 months
and receive a FREE box of Novo Nordisk needlesa
• Offer valid for both Tresiba® U-100 and U-200
Maximum savings of $150 per 30-day supply. Limit 1 box of needles per person and

1:1 conversion until expiration date or store at room

a

maximum savings of $60. Needles are sold separately and may need a prescription in some
states. Needles must not be shared. Eligibility and other restrictions apply. See back for details.
BASAL

temperature (<86°F) for 8 weeks

Pediatric patients (≥1 year) with T1D
Eligible patients pay as little as $5
or T2D1: 80% of the total daily long- Opened1: Refrigerate (36°F-46°F) or store at
per 30-day supply for up to 24 months
or intermediate-acting insulin unit dose room temperature (<86°F) for 8 weeks
(Maximum savings of $150 per 30-day supply.)
BASAL/GLP-1 RA

Currently on basal insulin or a Prior to first use2: Refrigerate (36°F-46°F)

GLP-1 RA: Discontinue therapy until expiration date
with basal insulin or liraglutide prior to After first use2: Refrigerate (36°F-46°F)
initiation of Xultophy® 100/3.62 Eligible patients pay as little as $1 per day
or store at room temperature (59°F-86°F)
for up to 2 years (Maximum monthly savings
Recommended starting dose : 16 units2
for 21 days
of $400. Up to 24 months.)

Unopened3: Refrigerate (36°F-46°F)

until expiration date or store at room
PRANDIAL

temperature (<86°F) for 28 days

1:1 conversion from other mealtime insulins3 Opened3: Refrigerate (36°F-46°F) or store at
room temperature (<86°F) for 28 days Eligible patients pay as little as $25 per
30-day supply up to 2 years (Maximum savings
Once opened, DO NOT refrigerate up to $100 per 30-day supply.)
PenFill® cartridges

a
Needles are sold separately and may require a prescription in some states.
b
Eligibility and other restrictions apply. See page 6 for details.

Tresiba® Important Safety Information (cont’d) Xultophy® 100/3.6 Important Safety Information Fiasp® Important Safety Information (cont’d)
Warnings and Precautions (cont’d) (cont’d) Warnings and Precautions (cont’d)
• Hypoglycemia is the most common adverse reaction of insulin, including Warnings and Precautions (cont’d) • Hypoglycemia is the most common adverse reaction of insulin, including
Tresiba®, and may be life-threatening. Increase monitoring with changes to: • Pancreatitis: Acute pancreatitis, including fatal and non-fatal hemorrhagic or Fiasp®, and may be life-threatening. Increase glucose monitoring with
insulin dose, co-administered glucose lowering medications, meal pattern, necrotizing pancreatitis, has been observed in patients treated with liraglutide changes to: insulin dosage, co-administered glucose lowering medications,
physical activity; and in patients with hypoglycemia unawareness or renal or postmarketing. Observe patients carefully for signs and symptoms of pancreatitis meal pattern, physical activity; and in patients with renal impairment or
hepatic impairment (persistent severe abdominal pain, sometimes radiating to the back with or hepatic impairment or hypoglycemia unawareness.
• Accidental mix-ups between basal insulin products and other insulins, without vomiting). If pancreatitis is suspected, discontinue Xultophy® 100/3.6 • To avoid medication errors and accidental mix-ups between Fiasp® and
particularly rapid-acting insulins, have been reported. To avoid medication promptly and if pancreatitis is confirmed, do not restart. Liraglutide, one of the other insulin products, instruct patients to always check the insulin label
errors, always instruct patients to check the insulin label before each injection components of Xultophy® 100/3.6, has been studied in a limited number of before injection.
• Severe, life-threatening, generalized allergy, including anaphylaxis, can occur patients with a history of pancreatitis. It is unknown if patients with a history of • As with all insulins, Fiasp® use can lead to life-threatening hypokalemia,
with insulin products, including Tresiba® pancreatitis are at a higher risk for development of pancreatitis on liraglutide. which then may cause respiratory paralysis, ventricular arrhythmia, and
•N ever Share a Xultophy ® 100/3.6 Pen Between Patients, even if the needle is death. Monitor potassium levels in patients at risk for hypokalemia and treat
changed. Sharing of the pen poses a risk for transmission of blood-borne pathogens. if indicated.
Click here for Prescribing Information for Tresiba®. • Severe, life-threatening, generalized allergy,
Click here for Prescribing Information, including Boxed Warning, for Xultophy® 100/3.6. including anaphylaxis, may occur with insulin
products, including Fiasp®.
Click here for Prescribing Information for Fiasp®.
Please see additional Important Safety Information for Tresiba®, Xultophy® 100/3.6, and Fiasp® throughout.
 OTHER INSULIN PRODUCTS FROM NOVO NORDISK4-10
4

10 mL multiple-dose vial
NDC: 0169-7501-11 10 mL vial NDC: 0169-1834-11
3 mL single-patient-use PenFill® cartridges N ReliOn® brand NDC: 0169-1834-02
NDC: 0169-3303-12 3 mL FlexPen® NDC: 0169-3004-15
3 mL single-patient-use NovoLog® FlexPen® ReliOn® brand NDC: 0169-3004-25
NDC: 0169-6339-10
Click here for Prescribing Information for Click here for Prescribing Information for
NovoLog®. Novolin® N.

10 mL multiple-dose vial 10 mL vial NDC: 0169-1833-11

NDC: 0169-3685-12 ReliOn® brand NDC: 0169-1833-02
insulin aspart protamine and 3 mL single-patient-use NovoLog® MIX 70/30 FlexPen® 3 mL FlexPen® NDC: 0169-3003-15
insulin aspart injectable suspension 100 Units/mL NDC: 0169-3696-19 ReliOn® brand NDC: 0169-3003-25

Click here for Prescribing Information for Click here for Prescribing Information for
NovoLog® Mix 70/30. Novolin® R.

3 mL single-patient-use Levemir® FlexTouch®

GlucaGen® HypoKit®
NDC: 0169-6438-10
NDC: 0169-7065-15
10 mL multiple-dose vial Includes: 1 single-dose vial containing 1 mg GlucaGen® (glucagon)
NDC: 0169-3687-12 for injection (NDC: 0169-7065-15), 1 disposable syringe containing
1 mL Sterile Water for Reconstitution
Click here for Prescribing Information for GlucaGen® Diagnostic Kit
Levemir®. NDC: 0597-0260-10
Includes: 1 single-dose vial containing 1 mg GlucaGen® (glucagon)
for injection (NDC: 0597-0053-01), 1 vial containing 1 mL Sterile
Click here for Prescribing Information for Water for Reconstitution (NDC: 0597-0265-94)
GlucaGen®. GlucaGen® 10-pack
10 mL vial NDC: 0169-1837-11
NDC: 0597-0053-45
ReliOn® brand NDC: 0169-1837-02
Includes: 10 single-dose vials, each containing 1 mg
3 mL FlexPen® NDC: 0169-3007-15 GlucaGen® (glucagon) for injection
ReliOn® brand NDC: 0169-3007-25

Click here for Prescribing Information for

Novolin® 70/30.

Click here for Prescribing Information for Tresiba®.

Click here for Prescribing Information, including Boxed Warning, for Xultophy® 100/3.6.
Click here for Prescribing Information for Fiasp®.
Please see additional Important Safety Information for Tresiba®, Xultophy® 100/3.6, and Fiasp® throughout.
 5
Tresiba® Important Safety Information (cont’d) Xultophy® 100/3.6 Important Safety Information (cont’d)
Warnings and Precautions (cont’d) Warnings and Precautions (cont’d)
• As with all insulins, Tresiba® use can lead to life-threatening hypokalemia, which then may cause respiratory paralysis, ventricular •H  ypokalemia: All insulin containing products, including Xultophy® 100/3.6 can lead to life-threatening hypokalemia,
arrhythmia, and death. Closely monitor potassium levels in patients at risk of hypokalemia and treat if indicated which may then cause respiratory paralysis, ventricular arrhythmia, and death. Monitor potassium levels in patients at risk for
• Fluid retention and heart failure can occur with concomitant use of thiazolidinediones (TZDs), which are PPAR-gamma agonists, hypokalemia and treat if indicated.
and insulin, including Tresiba®. Patients should be observed for signs and symptoms of heart failure. If heart failure occurs, dosage • F luid Retention and Congestive Heart Failure: Patients using insulin containing products, including Xultophy® 100/3.6,
reduction or discontinuation of the TZD must be considered with thiazolidinediones (TZDs) should be observed for signs and symptoms of heart failure. If heart failure develops, dosage
reduction or discontinuation of the TZD must be considered.
Adverse Reactions
• Adverse reactions commonly associated with Tresiba® are hypoglycemia, allergic reactions, injection site reactions, lipodystrophy, Adverse Reactions
pruritus, rash, edema, and weight gain • The most common adverse reactions, reported in ≥5% of patients treated with Xultophy® 100/3.6 are nasopharyngitis,
headache, nausea, diarrhea, increased lipase and upper respiratory tract infection.
Drug Interactions
• There are certain drugs that may cause clinically significant drug interactions with Tresiba®. Drug Interactions
— Drugs that may increase the risk of hypoglycemia: antidiabetic agents, ACE inhibitors, angiotensin II receptor blocking agents, • Certain drugs may affect glucose metabolism, requiring dose adjustment and close monitoring of blood glucose. The signs and
disopyramide, fibrates, fluoxetine, monoamine oxidase inhibitors, pentoxifylline, pramlintide, salicylates, somatostatin analog symptoms of hypoglycemia may be reduced or absent in patients taking anti-adrenergic drugs (e.g., beta-blockers, clonidine,
(e.g., octreotide), sulfonamide antibiotics, GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT-2 inhibitors guanethidine, and reserpine).
—D  rugs that may decrease the blood glucose lowering effect: atypical antipsychotics (e.g., olanzapine and clozapine), • Liraglutide-containing products, including Xultophy® 100/3.6, cause a delay of gastric emptying, and thereby have the potential
corticosteroids, danazol, diuretics, estrogens, glucagon, isoniazid, niacin, oral contraceptives, phenothiazines, progestogens to impact the absorption of concomitantly administered oral medications. Caution should be exercised when oral medications are
(e.g., in oral contraceptives), protease inhibitors, somatropin, sympathomimetic agents (e.g., albuterol, epinephrine, terbutaline), concomitantly administered with liraglutide-containing products.
and thyroid hormones Use in Specific Populations
—D  rugs that may increase or decrease the blood glucose lowering effect: alcohol, beta-blockers, clonidine, lithium salts, • Xultophy® 100/3.6 should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
and pentamidine
—D  rugs that may blunt the signs and symptoms of hypoglycemia: beta-blockers, clonidine, guanethidine, and reserpine
Fiasp® Important Safety Information (cont’d)
Xultophy® 100/3.6 Important Safety Information (cont’d) Warnings and Precautions (cont’d)
• Fluid retention and heart failure can occur with concomitant use of thiazolidinediones (TZDs), which are PPAR-gamma agonists,
Warnings and Precautions (cont’d) and insulin, including Fiasp®. Patients should be observed for signs and symptoms of heart failure. If heart failure occurs,
• Hyperglycemia or Hypoglycemia with Changes in Insulin Regimen: Changes in an insulin regimen (e.g., insulin dosage reduction or discontinuation of the TZD must be considered.
strength, manufacturer, type, or injection site or method of administration) may affect glycemic control and predispose to • Pump or infusion set malfunctions can lead to a rapid onset of hyperglycemia and ketoacidosis. Prompt identification and
hypoglycemia or hyperglycemia. Repeated insulin injections into areas of lipodystrophy or localized cutaneous amyloidosis have correction of the cause of hyperglycemia or ketosis is necessary. Interim therapy with subcutaneous injection of Fiasp® may
been reported to result in hyperglycemia; and a sudden change in the injection site (to an unaffected area) has been reported be required. Patients using continuous subcutaneous insulin infusion pump therapy must be trained to administer insulin by
to result in hypoglycemia. Make any changes to a patient’s insulin regimen under close medical supervision with increased injection and have alternate insulin therapy available in case of pump failure.
frequency of blood glucose monitoring. Advise patients who have repeatedly injected into areas of lipodystrophy or localized
cutaneous amyloidosis to change the injection site to unaffected areas and closely monitor for hypoglycemia. Adjustments in Adverse Reactions
concomitant anti-diabetic treatment may be needed. • Adverse reactions observed with Fiasp® include hypoglycemia, allergic reactions, hypersensitivity, injection site reactions,
• Overdose Due to Medication Errors: Instruct patients to check the label before each injection since accidental mix-ups lipodystrophy, and weight gain.
with insulin containing products can occur. Do not administer more than 50 units of Xultophy® 100/3.6 daily. Do not exceed
the 1.8 mg maximum recommended dose of liraglutide or use with other GLP-1 RAs.
Use in Specific Populations
• Pediatric patients with type 1 diabetes treated with mealtime and postmeal Fiasp® reported a higher rate of blood glucose
• Hypoglycemia: Hypoglycemia is the most common adverse reaction of insulin-containing products, including Xultophy® 100/3.6,
confirmed hypoglycemic episodes compared to patients treated with NovoLog® (insulin aspart injection); the imbalance was
and may be life-threatening. Increase monitoring with changes to: dose, co-administered glucose lowering medications, meal
greater during the nocturnal period. Monitor blood glucose levels closely in pediatric patients.
pattern, physical activity; and in patients with hypoglycemia unawareness or renal or hepatic impairment.
• Like all insulins, Fiasp® requirements may be reduced in patients with renal impairment or hepatic impairment. These patients
• Acute Kidney Injury: Acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis,
may require more frequent blood glucose monitoring and dose adjustments.
have been reported postmarketing for liraglutide, usually in association with nausea, vomiting, diarrhea, or dehydration.
Advise patients of the potential risk of dehydration due to gastrointestinal adverse reactions and take precautions to avoid
fluid depletion.
•H  ypersensitivity and Allergic Reactions: Severe, life-threatening, generalized allergy, including anaphylaxis, angioedema,
bronchospasm, hypotension, and shock can occur. If a hypersensitivity reaction occurs, discontinue and treat per standard
of care. Anaphylaxis and angioedema have been reported with other GLP-1 RAs. Use caution in a patient with a history of
anaphylaxis or angioedema with other GLP-1 RAs because it is unknown whether such patients will be predisposed to these
reactions with Xultophy® 100/3.6.
• Acute Gallbladder Disease: In a cardiovascular outcomes trial (LEADER trial) 3.1% of patients treated with liraglutide, one
of the components of Xultophy® 100/3.6, versus 1.9% of placebo treated patients reported an acute event of gallbladder
disease, such as cholelithiasis or cholecystitis. The majority of events required hospitalization or cholecystectomy. If cholelithiasis
is suspected, gallbladder studies and appropriate clinical follow-up are indicated.

Click here for Prescribing Information for Tresiba®.

Click here for Prescribing Information, including Boxed Warning, for Xultophy® 100/3.6.
Click here for Prescribing Information for Fiasp®.
Please see additional Important Safety Information for Tresiba®, Xultophy® 100/3.6, and Fiasp® throughout.
 6
NOVO NORDISK SAVINGS CARD
Eligibility and Restrictions:
In order to redeem this offer patient must have a valid prescription for the brand being filled. A valid Prescriber ID# is
required on the prescription. Patient is not eligible if he/she participates in or seeks reimbursement or submits a claim for
reimbursement to any federal or state healthcare program with prescription drug coverage, such as Medicaid, Medicare,
Medigap, VA, DOD, TRICARE, or any similar federal or state health care program (each a Government Program), or where
prohibited by law. Patient must be enrolled in, and must seek reimbursement from or submit a claim for reimbursement
to, a commercial insurance plan. The brand and the prescription being filled must be covered by the patient’s commercial
insurance plan. Offer excludes full cash-paying patients. This offer may not be redeemed for cash. By using this offer, you are
certifying that you meet the eligibility criteria and will comply with the terms and conditions described herein and will not seek
reimbursement for any benefit received through this card. Novo Nordisk’s Eligibility and Restrictions, and Offer Details may
change from time to time, and for the most recent version, please visit http://www.novocare.com/eligibility/diabetes-savings-
card.html. Re-confirmation of information may be requested periodically to ensure accuracy of data and compliance with
terms. Patients with questions about the Savings Card offer may call 1-877-304-6855.
This offer is valid in the United States and may be redeemed at participating retail pharmacies. Absent a change in Massachusetts
law, effective January 1, 2020, the Savings Card will no longer be valid for residents of Massachusetts. Void where taxed,
restricted, or prohibited by law. This offer is not transferable and is limited to one offer per person. Not valid if reproduced.
Cash Discount Cards and other non-insurance plans are not valid as primary insurance under this offer. If the patient is eligible for
drug benefits under any such program, the patient cannot use this offer. This Savings Card cannot be combined with any coupon,
certificate, voucher, or similar offer.
Patient is responsible for complying with any insurance carrier co-payment disclosure requirements, including disclosing any
savings received from this program. It is illegal to (or offer to) sell, purchase, or trade this offer.
This program is managed by ConnectiveRx on behalf of Novo Nordisk. The parties reserve the right to rescind, revoke or amend
this offer without notice at any time.

Offer Details:
This offer is good for eligible patients purchasing up to a 90-day supply.
(a) FIASP® (insulin aspart injection) 100 U/mL, NOVOLOG® (insulin aspart injection) 100 U/mL,
NOVOLOG® MIX 70/30 (insulin aspart protamine and insulin aspart injectable suspension) 100 U/mL: Pay as little
as (“PALA”) $25 per 30-day, $50 per 60-day, or $75 per 90-day supply for the first brand for up to 24 months from the date of
Savings Card activation, subject to a maximum savings of $100 per 30-day (“Savings Benefit”), $200 per 60-day, or $300 per
90-day supply.
(b) LEVEMIR® (insulin detemir injection) 100 U/mL: Pay as little as (“PALA”) $45 per 30-day, $90 per 60-day, or $135 per
90-day supply for the first brand for up to 24 months from the date of Savings Card activation, subject to a maximum savings of
$100 per 30-day (“Savings Benefit”), $200 per 60-day, or $300 per 90-day supply.
(c) TRESIBA® (insulin degludec injection) 100 U/mL or 200 U/mL: Pay as little as (“PALA”) $5 per 30-day, $10 per 60-day,
or $15 per 90-day supply for up to 24 months from the date of Savings Card activation, subject to a maximum savings of $150
per 30-day, $300 per 60-day, or $450 per 90-day supply.
(d) XULTOPHY® 100/3.6 (insulin degludec and liraglutide injection) 100 U/mL and 3.6 mg/mL: Pay as little as
(“PALA”) $30 per 30-day, $60 per 60-day, or $90 per 90-day supply for up to 24 months from the date of Savings Card activation,
subject to a maximum savings of $400 per 30-day supply, $800 per 60-day, or $1,200 per 90-day supply.
Get one (1) free box of Novo Nordisk needles when you activate your Savings Card and enroll in the program. Limit 1 box of
needles per person and maximum savings of $60. Needles are sold separately, will need a prescription and need to be processed
by a pharmacist. Needles must not be shared.

Pharmacist: References: 1. Tresiba [package insert]. Plainsboro, NJ: Novo Nordisk Inc; November 2019. 2. Xultophy [package insert].
Plainsboro, NJ: Novo Nordisk Inc; November 2019. 3. Fiasp [package insert]. Plainsboro, NJ: Novo Nordisk Inc; December
When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any Government 2019. 4. NovoLog [package insert]. Plainsboro, NJ: Novo Nordisk Inc; November 2019. 5. NovoLog Mix [package insert].
Program for this prescription, or where prohibited by law. Participation in this program must comply with all applicable laws and Plainsboro, NJ: Novo Nordisk Inc; November 2019. 6. Levemir [package insert]. Plainsboro, NJ: Novo Nordisk Inc; December
regulations as a pharmacy provider. By participating in this program, you are certifying that you will comply with the eligibility 2019. 7. Novolin 70/30 [package insert]. Plainsboro, NJ: Novo Nordisk Inc; December 2019. 8. Novolin N [package insert].
criteria, and terms and conditions described herein. You also certify that you will not seek reimbursement for any benefit received Plainsboro, NJ: Novo Nordisk Inc; December 2019. 9. Novolin R [package insert]. Plainsboro, NJ: Novo Nordisk Inc;
through this card. December 2019. 10. GlucaGen [package insert]. Plainsboro, NJ: Novo Nordisk Inc; July 2018.

Pharmacist instructions for a patient with an Eligible Third Party:

Submit the claim to the primary Third Party Payer first, then submit the balance due to CHANGE HEALTHCARE as a Secondary Fiasp®, FlexPen®, FlexTouch®, GlucaGen®, Novolin® 70/30, Novolin® N, Novolin® R, NovoLog®,
Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code, (e.g. 8). The patient is NovoLog® Mix, Levemir®, PenFill®, Tresiba®, and Xultophy® 100/3.6 are registered trademarks of Novo Nordisk A/S.
responsible initially for the PALA amount and the card pays up to the Savings Benefit. Offer excludes full cash-paying patients. Novo Nordisk is a registered trademark of Novo Nordisk A/S.
Reimbursement will be received from CHANGE HEALTHCARE. For any questions regarding CHANGE HEALTHCARE online All other trademarks, registered or unregistered, are the property of their respective owners.
processing, please call the Help Desk at 1-800-433-4893. © 2020 Novo Nordisk US19FSP00218 January 2020