COBENFY™ (xanomeline and trospium chloride) Hospital Discharge Voucher Program
Eligibility Requirements:
You may be eligible for the COBENFY Hospital Discharge Voucher if you meet all the following requirements:
- You have not previously received a sample or filled a prescription for COBENFY
- You have a valid prescription for COBENFY
- You are being treated with COBENFY for an FDA-approved indication
- You are 18 years of age or older
- You are a resident of the United States, Puerto Rico, or other U.S. Territory
Terms of use:
- Eligible patients who present an activated Hospital Discharge Voucher together with a valid prescription for COBENFY at participating pharmacies can receive up to a free 30 day supply (up to 60 capsules) of COBENFY. Patient is responsible for applicable taxes, if any. This offer may not be redeemed on prescriptions written for longer than 30 days.
- This offer is limited to one Hospital Discharge Voucher per patient per lifetime and is non-transferable. By redeeming this offer, patients certify that they have not previously filled a prescription for COBENFY.
- This free trial cannot be combined with any other rebate, coupon, free trial, discount to the patient, pharmacy or other third party, or similar offer. No substitutions are permitted.
- Patients, pharmacists, and prescribers cannot seek reimbursement for the COBENFY Hospital Discharge Voucher from health insurance, health savings or flexible spending accounts, or any third party, including state or federally funded programs.
- Patients may not count the COBENFY Hospital Discharge Voucher as an expense incurred for purposes of determining out-of-pocket costs for any plan, including true out-of-pocket costs (TrOOP), or for purposes of calculating the out-of-pocket threshold for Medicare Part D plans.
- The Hospital Discharge Voucher is for the benefit of the patient only.
- Activation is not required. This card expires on December 31, 2026.
- Only valid in the United States, Puerto Rico, and other U.S. Territories; this offer is void where restricted or prohibited by law.
- Bristol Myers Squibb reserves the right to rescind, revoke, or amend this offer at any time without notice.
- This Hospital Discharge Voucher card may not be sold, purchased, traded, or counterfeited. Reproductions of this card are void.
- This offer is not conditioned on any past, present, or future purchase, including refills.
- The COBENFY Hospital Discharge Voucher is not health insurance.
BY USING THIS CARD, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.
To the pharmacist: For processing assistance, please call the Pharmacy Helpdesk at 1-800-657-7613.