XARELTO withMe Trial Offer

Free 30-day trial supply for eligible patients beginning treatment with XARELTO®

With the XARELTO withMe Trial Offer, you are able to try XARELTO® at no cost to see if it’s right for you. At the conclusion of the program, you and your healthcare provider decide whether to continue treatment. Terms expire at the end of each calendar year and may change.
What do I get when I use my Trial Offer card?
You’re eligible to receive a free 30-day supply of XARELTO® with a valid signed 30-day prescription. You can also use it with a XARELTO® Starter Pack.
Where can I use my Trial Offer card?
Present the XARELTO withMe Trial Offer information to your pharmacist with your written prescription for XARELTO® to receive your free trial.
Am I eligible?
  • You may be eligible for the XARELTO withMe Trial Offer if you have been prescribed XARELTO®, except if you are taking XARELTO® 10-mg tablet or 1 mg/mL oral suspension.
  • The XARELTO withMe Trial Offer is open to patients who have commercial insurance, government coverage, or no insurance coverage; however, there is no guarantee of continuous accessibility after the program ends.
Other requirements
  • Patients enrolled in a Medicare Part D plan are eligible for this free 30-day trial offer but may not submit a claim for the costs paid by this program to count toward true out-of-pocket (TrOOP) costs.
  • Patients may not seek payment for the value received from this program from any health plan, patient assistance foundation, flexible spending account, or healthcare savings account.
  • One (1) use is allowed per lifetime.
  • Terms expire at the end of each calendar year. The program may change or end without notice, including in specific states.
  • By using the Trial Offer, you confirm that you have read, understood, and agree to the program requirements.
  • You will be asked to provide personal information that may include your name, address, phone number, email address, and information related to your prescription medication insurance and treatment. This information is needed for Johnson & Johnson Health Care Systems Inc. and our service providers to enroll you in the XARELTO withMe Trial Offer Program. We may also use the information you give us to learn more about the people who use XARELTO®, and to improve the information we give them. Johnson & Johnson Health Care Systems Inc. will not share your information with anyone else except where legally allowed.
  • This program offer may not be used with any other coupon, discount, prescription savings card, free trial, or other offer. Offer good only in the United States and its territories. Void where prohibited, taxed, or limited by law.

You may end your participation in XARELTO withMe at any time by calling 888-XARELTO (888-927-3586).

Patient Information
This form is intended to be used by patients registering for the XARELTO withMe Trial Offer. The information you provide will be used by Johnson & Johnson Health Care Systems Inc., our affiliates, and our service providers for your participation in the XARELTO withMe Trial Offer. Our Privacy Policy further governs the use of information you provide.
  
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By providing and submitting this information, you agree that you will speak with or have spoken to your healthcare professional to learn more about what is required to receive XARELTO®. In addition, you indicate that you read, understand, and agree with these program requirements, and wish to participate in the XARELTO withMe Trial Offer.

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Please read the full Prescribing Information, including Boxed Warnings, and Medication Guide for XARELTO®, and discuss any questions you have with your doctor.