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

Use the information below to process the AUSTEDO XR 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 ID:

610020

PDMI

99995240

2705467256

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

To the Patient:

    • This Free Trial offer authorizes a pharmacist to dispense up to a 30-day supply of AUSTEDO XR/AUSTEDO at no cost to you when presented with a valid prescription from a qualified healthcare provider. This offer is invalid at any pharmacy that does not accept free trial offers. Other Terms, Conditions, and Eligibility Criteria apply—please see below.
    • 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.
    • Patients who have received an AUSTEDO XR or AUSTEDO sample are not eligible for this offer.

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.
  • For reimbursement, please submit electronically to PDMI. The information printed on the Free Trial Voucher should be used when submitting for reimbursement. For questions, please call the PDMI Help Desk at 1-800-800-7364. Program expires December 31, 2024.

Terms, Conditions, and Eligibility Criteria

  1. This program is not contingent on a purchase of any kind.
  2. The Voucher may be redeemed for a single 30-day supply of AUSTEDO XR or AUSTEDO per patient (including up to 3 NDCs).
  3. Patients must be new to AUSTEDO XR/AUSTEDO and have not previously filled a prescription for AUSTEDO XR/AUSTEDO.
  4. Patients must have a valid, signed prescription(s) for AUSTEDO XR/AUSTEDO.
  5. 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 only when patients, pharmacists, and prescribers agree not to seek reimbursement from health insurance, health savings or flexible spending accounts, or any third party, including state or federally funded programs for the Free Trial of AUSTEDO XR/AUSTEDO received by the patient through this offer.
  6. 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.
  7. 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.
  8. This offer may be changed or discontinued at any time without notice. This offer expires on December 31, 2024.
  9. Patients are responsible for applicable taxes, if any.
  10. By redeeming this Free Trial Voucher, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer.
  11. For questions regarding eligibility, please call Paysign at 1.844.308.5110.