Welcome to the AUSTEDO® (deutetrabenazine) tablets free trial voucher card. Use the exact language highlighted in blue below to initiate Austedo Copay card in your system.

Voucher
BIN: 004682
PCN: CN
Group Member: EV74009004
Member ID: 29158537093

Free Trial Voucher for AUSTEDO® (deutetrabenazine) Tablets Eligibility, Terms and Conditions:

  • Patients must be new to AUSTEDO® and have not previously filled a prescription for AUSTEDO.
  • Patients must have a valid, signed prescription(s) for AUSTEDO®. The Free Trial Voucher may only be redeemed for four weeks of titration or up to a thirty day supply of maintenance. The Voucher may be redeemed for up to a total of three prescriptions with only one prescription per Austedo strength or NDC to achieve up to a single 30 day supply.
  • This offer may be used by cash paying patients, patients with commercial insurance and patients who are eligible for or participate in federal healthcare programs such as Medicaid, Medicare, or any similar federal or state programs. 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® received by the patient through this offer.
  • 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.
  • If the patient has prescription drug insurance, the assistance offered by the Free Trial Voucher must be consistent with the patient’s insurance and patient must report the value received as may be required by his/her insurance provider.
  • 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.
  • No purchase is required. 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, 2020.
  • This Free Trial Voucher is not conditioned on any past, present or future purchase, including refills.
  • Patients are responsible for applicable taxes, if any.
  • For questions regarding eligibility, please call ConnectiveRx at 844.247.4098.

To the Pharmacist:

  • By using this voucher, you are certifying that you understand and agree to comply with the Eligibility requirements and Terms and Conditions above.
  • The Voucher may be redeemed for up to a total of three prescriptions with only one prescription per AUSTEDO® strength or NDC to achieve up to a single 30 day supply.
  • 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, 2020.