IMBRUVICA® VOUCHER PROGRAM
FREE TRIAL OFFER† FOR ELIGIBLE NEW PATIENTS INITIATING THERAPY
IMBRUVICA® FREE UP TO 1-MONTH SUPPLY
Free Trial Offer for eligible commercial, Medicare, Medicaid or cash patients
†Subject to eligibility rules; limits and restrictions apply
Just 3 easy steps to provide up to 1-month free supply of IMBRUVICA®
Pharmacy Instructions

Complete the form below and click “Submit”. Any field marked (*) is required.

Print the voucher from the confirmation page and attach it to a new prescription for IMBRUVICA®.

In the confirmation, please follow the instructions outlined for processing the voucher and for reimbursement.
For questions completing the form, please call 1-855-332-6211
*Required
Only new patients initiating therapy on IMBRUVICA® are eligible for this voucher program.
Current IMBRUVICA® patients can visit IMBRUVICA® By Your Side patient support.
Success! Print this page and attach to a new prescription for IMBRUVICA®
FREE UP TO 1-MONTH TRIAL OFFER FOR NEW IMBRUVICA® PATIENTS
Eligible* patients will receive up to a one month† free supply of IMBRUVICA®
*Some restrictions apply. See eligibility rules for details.
For Eligible NEW Patients Initiating Therapy
Limit one voucher per patient for the duration of the program.
This offer will be accepted only at participating pharmacies.
Program managed by McKesson on behalf of Pharmacyclics LLC and Janssen Biotech, Inc.
IMBRUVICA®
Free up to a 1-Month† supply
†Up to 1-month supply of IMBRUVICA®
capsules, tablets, or oral suspension
Free Trial Off er for eligible‡ commercial, Medicare, Medicaid, or cash patients.
This voucher is valid once per patient for up to a 1-month§ trial of IMBRUVICA®.
28-day supply: 140 mg, 280 mg, 420 mg, 560 mg tablets, or 70 mg capsules
30-day supply: 140 mg capsules
Up to 1-month supply: 1 bottle/108 mL; oral suspension
‡Limits, terms and conditions apply.
§Capsules, tablets, and oral suspension
Patients may be offered the free trial voucher exclusively through their healthcare provider. The prescription must be filled through a participating pharmacy. There is no obligation to continue IMBRUVICA®. To continue a patient on IMBRUVICA® therapy, a prescription can be filled through a participating pharmacy. If you have questions or need a list of participating pharmacies, please call the Help Desk at 1-855-332-6211.
FREE TRIAL OFFER FOR ELIGIBLE COMMERCIAL, MEDICARE, MEDICAID OR CASH PATIENTS.
By using this voucher, the patient and pharmacist understand and agree to comply with these eligibility requirements and terms of use. This offer is good for eligible patients on IMBRUVICA® who are residents of the United States, Puerto Rico, US Virgin Islands, or Guam, and have a valid prescription for IMBRUVICA® written within the last 30 days. Only patients new to IMBRUVICA® may use this voucher. These eligible patients can receive up to a month supply of IMBRUVICA®. This Free Trial Offer cannot be combined with any other savings, free trial, or similar offer for the specified prescription. This offer will be accepted only at participating pharmacies. 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), or for purposes of calculating the out-of-pocket threshold for Medicare Part D plans. This voucher is not valid where prohibited by law. This free trial offer is not health insurance. This free trial offer may not be sold, purchased, traded or counterfeited. Patients have no obligation to continue to use IMBRUVICA®. Pharmacyclics/Janssen reserves the right to rescind, revoke or amend this offer at any time without notice. Program terms will expire at the end of each calendar year. For questions, please call the Help Desk at 1-855-332-6211. For information on how Pharmacyclics and Janssen handle personal information, please visit their privacy notices at https://www.pharmacyclics.com/privacy-policy and https://www.janssen.com/us/privacy-policy.
BY USING THIS VOUCHER, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.
Pharmacist Instructions:
For reimbursement, please submit this voucher as a primary claim using BIN# 610524. The information printed on the front combined with the ID# provided on the voucher should be used when submitting for reimbursement. No claim for payment can be made to ANY Third-Party Payer for product dispensed pursuant to this offer. Not valid if reproduced. For any questions regarding online processing, please call the Help Desk at 1-855-332-6211.
You are encouraged to report negative side effects to the FDA by visiting www.FDA.gov/medwatch or calling 1-800-FDA-1088.
Program managed by McKesson on behalf of Pharmacyclics LLC and Janssen Biotech. Product dispensed pursuant to program rules and federal and state laws.
© Pharmacyclics LLC 2022 © Janssen Biotech, Inc. 2022 08/22 PRC-09679
This submission cannot be processed.
Thank you for submitting this application for the IMBRUVICA® Voucher Program.
Based on the information submitted, there is an issue with this request. Please call the McKesson Pharmacy Help Desk at 1-855-332-6211. We are available to answer your questions Monday through Friday 8:00am-8:00pm ET, excluding holidays.
Current IMBRUVICA® patients can visit: https://imbruvica.com/imbruvica-by-your-side.
Pharmacy: This requires patient consent in order to opt-in
Pharmacyclics LLC and Janssen Biotech, Inc. provide personalized support programs. Pharmacyclics LLC, Janssen Biotech, Inc., its affiliates, service providers, and co-promotion partners will use the patient's personal information, including health information, collected through enrollment and participation in the programs to: 1. provide the patient with Pharmacyclics LLC and Janssen Biotech, Inc. product-related support and communications; and 2. perform research and analytics. The patient will be able to opt out of these additional communications at any time by calling 1-855-332-6210. The ability to use the IMBRUVICA® voucher is not contingent on enrollment in the manufacturer’s patient support program. For information on how Pharmacyclics and Janssen handle personal information, please visit their privacy notices at https://www.pharmacyclics.com/privacy-policy and https://www.janssen.com/us/privacy-policy.
By using this voucher, the patient and pharmacist understand and agree to comply with these eligibility requirements and terms of use: This offer is good for eligible patients on IMBRUVICA® who are residents of the United States, Puerto Rico, US Virgin Islands or Guam, and have a valid prescription for IMBRUVICA® written within the last 30 days. Only patients new to IMBRUVICA® may use this voucher. These eligible patients can receive up to a month's† supply of IMBRUVICA®. Offer is limited to one per patient and is not transferable. The Free Trial Offer cannot be combined with any other savings, free trial or similar offer for the specified prescription. This voucher will be accepted only at participating pharmacies. 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), or for purposes of calculating the out-of-pocket threshold for Medicare Part D plans. This voucher is not valid where prohibited by law. The Free Trial Offer is not health insurance. This free trial offer may not be sold, purchased, traded or counterfeited. Patients have no obligation to continue to use IMBRUVICA®. Pharmacyclics/Janssen reserves the right to rescind, revoke, or amend this offer at any time without notice. For questions, please call the Help Desk at 1-855-332-6211. For information on how Pharmacyclics and Janssen handle personal information, please visit their privacy notices at https://www.pharmacyclics.com/privacy-policy and https://www.janssen.com/us/privacy-policy.*