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Free Trial Offer
FREE 30-DAY TRIAL
ELIGIBLE* PATIENTS CAN RECEIVE A FREE 30-DAY SUPPLY
of KOMBIGLYZE® XR (saxagliptin and metformin HCI extended-release)
Limit one KOMBIGLYZE XR voucher per patient for the duration of the program.
Redeem for product only when accompanied by a valid 30-day prescription for KOMBIGLYZE XR.
For reimbursement, please submit to Patient Choice. The information printed on this offer should be
used when submitting for reimbursement.
For pharmacy processing questions, please call the Helpdesk at 1-800-422-5604.
BIN: 004682 |GRP: EV57012019
PCN: CN
| ID: 413702178625
Please see US full Prescribing Information and Medication Guide including Boxed WARNING for KOMBIGLYZE XR (5/500•5/1000•2.5/1000 mg tablets).
*Subject to eligibility. Restrictions apply. See full Eligibility Requirements and Terms of Use below.
Pharmacist Instructions: Limit one voucher per patient for the duration of the program. Redeem for product only when
accompanied by a valid prescription for a 30-day supply of KOMBIGLYZE XR. Voucher may not be redeemed on prescriptions
written for longer than 30 days. For reimbursement, please submit to Patient Choice. The information printed on this offer should be
used when submitting for reimbursement. For pharmacy processing questions, please call the Helpdesk at 1-800-422-5604.
Void where prohibited by law. No claim for payment can be made to ANY Third-Party Payer for product dispensed pursuant to this
offer. Not valid if reproduced. This voucher may not be sold, purchased, traded, counterfeited or reproduced.
Must be 18 years of age or older. This voucher is not insurance. AstraZeneca reserves the right to rescind, revoke or amend this offer
at any time without notice. Full eligibility requirements and terms of use are available below.
Physician Instructions: To use this voucher, your patient needs a signed prescription for a 30-day supply of KOMBIGLYZE XR.
You will need to provide a second prescription based on your recommended therapy if you want to keep your patient on
KOMBIGLYZE XR beyond the 30-day free trial free period. This voucher is not valid for refills.
Eligible Patient Instructions: Present prescription, along with this page, to the pharmacist to receive a free 30-day supply of
KOMBIGLYZE XR. If you have any questions regarding this offer, please call 1-800-236-9933.
ELIGIBILITY REQUIREMENTS
You may be eligible for the Free Trial Offer if:
• You have a valid prescription for KOMBIGLYZE XR, and this is the first time you are filling a prescription
• You are 18 years of age or older, and
• You are a resident of the United States or Puerto Rico
TERMS OF USE
• Eligible patients who present a Free Trial Offer voucher together with:
• a valid 30-day prescription for KOMBIGLYZE XR at participating pharmacies can receive a free 30-day supply of
KOMBIGLYZE XR. This voucher may not be redeemed on prescriptions written for longer than 30 days
• Patient is responsible for applicable taxes, if any
• This offer is limited to one use per product/per patient/per lifetime and is non-transferable. By redeeming this offer, you certify that
you have not previously filled a prescription for KOMBIGLYZE XR
• The Free Trial Offer cannot be combined with any other rebate/coupon, free trial or similar offer. No substitutions are permitted
• Patients, pharmacists and prescribers cannot seek reimbursement for the Free Trial Offer from health insurance or any third party,
including state or federally funded programs
• Patients may not count the Free Trial Offer as an expense incurred for purposes of determining out-of-pocket costs for any plan,
including true out-of-pocket costs, (“TrOOP”), for purposes of calculating the out-of-pocket threshold for Medicare Part D plans
• This offer will expire on December 31, 2015
• AstraZeneca reserves the right to rescind, revoke or amend this offer at any time without notice
• This Free Trial Offer voucher may not be sold, purchased, traded, or counterfeited. Reproductions of this voucher are void
• This offer is not conditioned on any past, present or future purchase, including refills
• The Free Trial Voucher is not insurance
BY USING THIS VOUCHER, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY
REQUIREMENTS AND TERMS OF USE.
KOMBIGLYZE XR is a registered trademark of the AstraZeneca group of companies.
©2014 AstraZeneca. All rights reserved.
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