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  • Why?
  • Why?

  • Are you currently taking?
    Onglyza®
    Kombiglyze™ XR
    How long have you been diagnosed with this condition?



    Please indicate which treatments you have tried.
    Check all that apply.

    Biguanides

    such as metformin or metformin HCI

    DPP-4 Inhibitor

    such as sitagliptin

    Sulfonylurea

    such as glipizide (Glucotrol® and Glucotrol XL®), glyburide (Micronase®, Glynase®, and Diabeta®), and glimepiride (Amaryl®)

    TZDs (thiazolidinedione)

    such as pioglitazone HCI (Actos®), pioglitazone and metformin HCI (ACTOplus met®), or rosiglitazone (Avandia®)

    Insulin

    Other

    Not taking any medication

    None of the above


    * Which of the following best describes the PRIMARY type of health insurance you have?
    Please select one response.

    HMO, PPO, or POSMedicareMedicaidMedigap
    Department of Defense (DOD)
    Veteran's
    Administration (VA)
    TRICARENo health insurance
    * By redeeming your value card, you are permitting an agency acting on behalf of Bristol-Myers Squibb and AstraZeneca, to contact your healthcare provider if your insurance plan requires a Prior Authorization. Do you grant permission to Bristol-Myers Squibb and AstraZeneca to contact your healthcare provider if your insurance plan requires a prior authorization?

    Yes

    No

    To complete your registration, please read the statements below, then click Submit.

    I acknowledge that I will not use the Value Card if my prescription for Onglyza (saxagliptin) or Kombiglyze XR (saxagliptin and metformin HCl extended-release) is paid for in whole or in part by any federally or state funded health care program.

    I agree to the following: Bristol-Myers Squibb and AstraZeneca respect your personal health information. Certain information pertaining to your use of the Value Card for Onglyza and Kombiglyze XR will be shared with Bristol-Myers Squibb and AstraZeneca, the sponsors of the card. The information disclosed will include, but is not limited to, the date your prescription was filled, the number of pills dispensed by your pharmacist, and the dollar amount you were reimbursed through the Value Card program for Onglyza and
    Kombiglyze XR. This information will be available to Bristol-Myers Squibb and AstraZeneca, and third parties working on their behalf and will not be shared with anyone else.


    IMPORTANT SAFETY INFORMATION
    for KOMBIGLYZE XR (saxagliptin and metformin HCl extended-release) tablets
    Lactic Acidosis: Metformin hydrochloride, one of the medicines in KOMBIGLYZE XR (saxagliptin and metformin HCl extended-release), can cause a rare, but serious, side effect called lactic acidosis (a build-up of lactic acid in the blood) that can cause death. Lactic acidosis is a medical emergency and must be treated in a hospital. Stop taking KOMBIGLYZE XR and call your doctor right away if you get any of the following symptoms of lactic acidosis: feel very weak and tired, unusual (not normal) muscle pain, trouble breathing, unusual sleepiness or sleep longer than usual, unexplained stomach or intestinal problems with nausea and vomiting or diarrhea, feel cold (especially in your arms and legs), dizzy or lightheaded, or have a slow or irregular heartbeat.
    WHAT IS KOMBIGLYZE XR?
    KOMBIGLYZE XR (saxagliptin and metformin HCl extended-release) is a prescription medicine that contains saxagliptin and metformin hydrochloride. KOMBIGLYZE XR is used with diet and exercise to help control high blood sugar (hyperglycemia) in adults with type 2 diabetes. Your doctor will decide if treatment with both saxagliptin and metformin is right for you.

    KOMBIGLYZE XR should not be used to treat people with type 1 diabetes or diabetic ketoacidosis (increased ketones in the blood or urine).

    If you have had inflammation of the pancreas (pancreatitis), it is not known if you have a higher chance of getting pancreatitis while taking
    KOMBIGLYZE XR.

    You have a higher chance of getting lactic acidosis if you have kidney or liver problems, have congestive heart failure that requires treatment with medicines, drink a lot of alcohol (very often or short-term “binge” drinking), get dehydrated (lose a large amount of body fluids), have certain x-ray tests with injectable dyes or contrast agents, have surgery, have a heart attack, severe infection, or stroke, or are 80 years of age or older and have not had your kidney function tested.

    Do not take KOMBIGLYZE XR if you have kidney problems, have a condition called metabolic acidosis or diabetic ketoacidosis (increased ketones in the blood or urine), or are allergic to metformin hydrochloride, saxagliptin, or any of the ingredients in KOMBIGLYZE XR. Serious allergic reactions can occur with KOMBIGLYZE XR and may include swelling of the face, lips or throat, difficulty swallowing or breathing, swelling of the skin, hives, rash, itching, flaking, or peeling. If you have these symptoms, stop taking KOMBIGLYZE XR and contact your doctor right away.

    Serious side effects can happen to people taking KOMBIGLYZE XR, including inflammation of the pancreas (pancreatitis) which may be severe and lead to death. Before taking KOMBIGLYZE XR, tell your doctor if you ever had pancreatitis, gallstones, history of alcoholism, or high triglyceride levels. Stop taking KOMBIGLYZE XR and contact your doctor right away if you have pain in your stomach area (abdomen) that is severe and will not go away. The pain may be felt going from your abdomen through to your back. The pain may happen with or without vomiting. These may be symptoms of pancreatitis.

    Your doctor should do blood tests to check how well your kidneys are working before and during your treatment with KOMBIGLYZE XR.

    If you take KOMBIGLYZE XR with another medicine that can cause low blood sugar (hypoglycemia), such as sulfonylureas or insulin, you have a higher risk of having low blood sugar. Symptoms of low blood sugar include, shaking, sweating, rapid heartbeat, change in vision, hunger, headache and change in mood. Follow your doctor's instructions for treating low blood sugar.

    The most common side effects of KOMBIGLYZE XR include upper respiratory tract infection, stuffy or runny nose and sore throat, urinary tract infection, headache, diarrhea, and nausea and vomiting.

    Tell your doctor if you will be starting or stopping certain other types of medicines, such as antibiotics, or medicines that treat fungus or HIV/AIDS, as your doctor may need to change your dose of KOMBIGLYZE XR.

    Tell your doctor if you are pregnant, breast-feeding, or plan to become pregnant or breast-feed.

    Swallow KOMBIGLYZE XR whole; do not crush, cut, or chew.

    You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.


    Please click here for Medication Guide, and click here for US Full Prescribing Information for KOMBIGLYZE XR (saxagliptin and metformin HCl extended-release), including Boxed WARNING about lactic acidosis.

    IMPORTANT SAFETY INFORMATION
    for ONGLYZA (saxagliptin)
    Do not take ONGLYZA (saxagliptin) if you are allergic to any of its ingredients. Serious allergic reactions can occur with ONGLYZA and may include swelling of the face, lips or throat, difficulty swallowing or breathing, swelling of the skin, hives, rash, itching, flaking, or peeling. If you have these symptoms, stop taking ONGLYZA and contact your doctor right away.
    Serious side effects can happen to people taking ONGLYZA, including inflammation of the pancreas (pancreatitis) which may be severe
    and lead to death. Before taking ONGLYZA, tell your doctor if you ever had pancreatitis, gallstones, history of alcoholism, or high triglyceride levels. Stop taking ONGLYZA and contact your doctor right away if you have pain in your stomach area (abdomen) that is severe and will not go away. The pain may be felt going from your abdomen through to your back. The pain may happen with or without vomiting. These may be symptoms of pancreatitis.
    WHAT IS ONGLYZA?
    ONGLYZA (saxagliptin) is a prescription medicine used along with diet and exercise to lower blood sugar in adults with type 2 diabetes.

    ONGLYZA should not be used to treat people with type 1 diabetes or diabetic ketoacidosis (increased ketones in the blood or urine).

    If you have had inflammation of the pancreas (pancreatitis), it is not known if you have a higher chance of getting pancreatitis while taking ONGLYZA.
    When ONGLYZA is used with certain other diabetes medicines to treat high blood sugar, such as a sulfonylurea or insulin, the risk of low blood sugar (hypoglycemia) is higher. Symptoms of low blood sugar include shaking, hunger, sweating, headache, rapid heartbeat, change in mood, and change in vision. Follow your doctor's instructions for treating low blood sugar.

    When ONGLYZA is used with a thiazolidinedione (TZD), such as pioglitazone or rosiglitazone, to treat high blood sugar, peripheral edema (fluid retention) may become worse. If you have symptoms of peripheral edema, such as swelling of hands, feet, or ankles, call your doctor.

    The most common side effects with ONGLYZA include upper respiratory tract infection, urinary tract infection, and headache.

    Your doctor should test your blood to measure how well your kidneys are working before and during treatment with ONGLYZA. You may need a lower dose if your kidneys are not working well.

    Tell your doctor if you start or stop taking other medications, including antibiotics, antifungals or HIV/AIDS medications, as your doctor may need to change your dose of ONGLYZA.

    Tell your doctor if you are pregnant, breast-feeding, or plan to become pregnant or breast-feed.

    You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.


    Please click here for Medication Guide, and click here for US Full Prescribing Information for ONGLYZA (saxagliptin).