ORDER VEOZAH FREE TRIAL VOUCHERS

Fill out the form below to order up to 40 vouchers monthly to provide to your new patients for a 10-day free trial of VEOZAH. Only new patients may use this voucher. Patients who have previously used or are currently using VEOZAH are not eligible for this voucher offer.

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VEOZAH® (fezolinetant) free trial voucher

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First Name

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Quantity

Healthcare providers are limited to 40 vouchers per month and you have exceeded your montly limit.

Healthcare providers are limited to 40 vouchers per month and you have left.

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Healthcare providers are limited to 40 vouchers per month and you have exceeded your monthly limit.

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I have read and understand the Terms & Conditions.

Terms & Conditions

To the healthcare practitioner: By providing this voucher to an appropriate patient, you certify that you understand and agree to comply with the Terms and Conditions below and that you or your office site staff have reviewed the Terms and Conditions with the patient.

Voucher Terms and Conditions: This voucher may be redeemed for a 10-day supply of VEOZAH. Prescription is for the FDA-approved indication. Only new patients may use this voucher. Patients who have previously used or are currently using VEOZAH are not eligible for this voucher offer. A Member ID and a valid prescription from a US-licensed healthcare practitioner must be provided to the pharmacy. Product dispensed pursuant to this voucher cannot be resold or further distributed to any other third party. No claim for reimbursement for product dispensed pursuant to this voucher may be submitted to any third-party payor, including Medicare, Medicaid, or any other federal or state healthcare program. The value of the free product received through this voucher cannot be counted toward any insurance benefit out-of-pocket spending calculations, such as Medicare Part D True Out-of-Pocket (TrOOP) costs. The patient must be 18 years of age or older to use this voucher. This voucher is not valid where prohibited by law. This voucher has no cash value. The selling, purchasing, or counterfeiting of this voucher is strictly prohibited. This voucher is limited to one per patient and is non-transferable. The voucher cannot be combined with any other savings, free trial, or similar offer for VEOZAH. This voucher should not be combined with samples for VEOZAH. This voucher is not health insurance. This voucher is not intended to address delays or gaps in health insurance coverage for the specified prescription. Offer good only in the US. No purchase of VEOZAH or any other Astellas product is necessary. No membership fees. Patients have no obligation to use VEOZAH or any other Astellas product in the future. Astellas reserves the right to rescind, revoke, or amend this offer without notice. For questions, please call 1-800-657-7613.

You must read and understand the Terms & Conditions.

OFFICE POLICY COMPLIANCE ACKNOWLEDGMENT

By checking this box, I acknowledge that I am solely responsible for complying with any policies or procedures my facility has regarding the acceptance and/or use of vouchers, and I am in compliance with such policies or procedures.

You must agree to the Office Policy Compliance Acknowledgment.

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