Get started with the AUSTEDO XR (deutetrabenazine)
extended-release
tablets/
AUSTEDO (deutetrabenazine) tablets Free Trial Voucher.

Use the information below to process the AUSTEDO XR/AUSTEDO prescription through the Free Trial Voucher instead of the customer's insurance carrier.

30 DAYS Free

Free Trial Voucher for new patients*

Bin:

PCN:

Group Member:

Member ID:

004682

CN

EV74009004

39158587250

This Free Trial Voucher is not conditioned on any past, present, or future purchase, including refills. No purchase is required.

Terms and Conditions:

To the Patient:

    • This offer should be presented when the prescription is taken to the pharmacy. This offer is invalid at any pharmacy that does not accept free trial offers.
    • Patients eligible for the Free Trial may not count the Free Trial as an expense incurred for purposes of determining out-of-pocket costs for any plan, including true out-of-pocket costs (“TrOOP”), under Medicare Part D.

To the Pharmacist:

  • By redeeming this voucher, you are certifying that you understand and agree to comply with the Eligibility requirements and Terms and Conditions below.
  • The Voucher may be redeemed for up to a total of three prescriptions with only one prescription per AUSTEDO XR/AUSTEDO strength or NDC to achieve up to a single 30-day supply (maximum 120 Tablets).
  • AUSTEDO XR Example Rx:
  • Rx 1: 12 mg tablets: 1 tablet days 1-7, 1 tablet on days 8-14 (with 6 mg tablet) Qty: 14
  • Rx 2: 24 mg tablets: 1 tablet on days 15-21, and 1 tablet on days 22-28 (with 6 mg tablet) Qty: 14
  • Rx 3: 6 mg tablets: 1 tablet on days 8-14, and 1 tablet on days 22-28 Qty: 14
  • AUSTEDO Example Rx:
  • Rx 1: 6 mg tablets, Qty: 28, 1 tablet BID on days 1-7, and 1 tablet BID (with a 9 mg tablet) on days 22-28
  • Rx 2: 9 mg tablets, Qty: 28, 1 tablet BID on days 8-14, and 1 tablet BID (with a 6 mg tablet) on days 22-28
  • Rx 3: 12 mg tablets, Qty: 14, 1 tablet BID on days 15-21
  • For reimbursement, please submit electronically to CHANGE HEALTHCARE. The information printed below should be used when submitting for reimbursement. For questions, please call the Change Healthcare Help Desk at 1-800-422-5604. Program expires December 31, 2023.
  • Patients must be new to AUSTEDO XR/AUSTEDO and have not previously filled a prescription for AUSTEDO XR/AUSTEDO.
  • Patients must have a valid, signed prescription(s) for AUSTEDO XR/AUSTEDO. The Free Trial Voucher may only be redeemed for four weeks of titration or up to a 30-day supply of maintenance.
  • Patients, pharmacists, and prescribers may not seek reimbursement from health insurance, health savings or flexible spending accounts, or any third party, for the Free Trial of AUSTEDO XR/AUSTEDO received by the patient through this offer.
  • This offer is limited to one per patient and is nontransferable. This free trial offer cannot be combined with any other free trial, coupon, discount, prescription savings card or other offer. No substitutions are permitted.
  • This offer is not health insurance. This offer is restricted to the residents of the United States and Puerto Rico. Void where prohibited by law, taxed or restricted. Not valid in California or Massachusetts if an AB-rated generic equivalent becomes available for the product. This offer may be changed or discontinued at any time without notice. This offer expires on December 31, 2023.
  • Patients are responsible for applicable taxes, if any.
  • For questions regarding eligibility, please call ConnectiveRx at 844.247.4098.