Eligible Patients May
PAY AS LITTLE AS $25* PER 1-MONTH OR 3-MONTH PRESCRIPTION FILL
You may be eligible* for savings. Sign up now.
for full Prescribing Information, including Boxed Warning.
*Depending on insurance coverage, eligible patients may pay as little as $25
for each of up to 13 one-month
Lo Loestrin® Fe
prescription fills OR each of up to 4 three-month
Lo Loestrin® Fe
prescription fills. Check with your pharmacist for your
copay discount. Maximum savings limits apply; patient out-of-pocket expense will vary.
Offer not valid for patients enrolled in Medicare, Medicaid, or other federal or state
Please see back of card or click
for Program Terms, Conditions, and Eligibility Criteria.
Program Terms, Conditions, and Eligibility Criteria:
This offer is good for use only with a valid prescription for Lo Loestrin® Fe
(norethindrone acetate and ethinyl estradiol tablets, ethinyl estradiol tablets and ferrous fumarate
tablets) at the time the prescription is filled by the pharmacist and dispensed to the patient.
Depending on your insurance coverage, eligible patients may pay as little as $25
for each of up to thirteen (13) one-month prescription fills OR each of up to four (4)
three-month prescription fills. Check with your pharmacist for your copay discount.
Maximum savings limits apply; patient out-of-pocket expense will vary.
This offer is not valid for use by patients enrolled in Medicare, Medicaid, or other
federal or state programs (including any state pharmaceutical assistance programs),
or private indemnity or HMO insurance plans that reimburse you for the entire cost
of your prescription drugs. Patients may not use this offer if they are
Medicare-eligible and enrolled in an employer-sponsored health plan or prescription
drug benefit program for retirees. This offer is not valid for cash-paying patients.
Each card is valid for up to thirteen (13) prescription fills of a 28-day supply
each OR up to four (4) prescription fills of an 84-day supply each. Offer applies
only to prescriptions filled before the program expires on 6/30/18.
Allergan reserves the right to rescind, revoke, or amend this offer without notice.
Offer good only in the USA, including Puerto Rico, at participating retail pharmacies.
Void if prohibited by law, taxed, or restricted.
This card is not transferable. The selling, purchasing, trading, or counterfeiting of
this card is prohibited by law.
This card has no cash value and may not be used in combination with any other discount,
coupon, rebate, free trial, or similar offer for the specified prescription.
This offer is not health insurance.
This card expires June 30, 2018.
By redeeming this card, you acknowledge that you are an eligible patient and that
you understand and agree to comply with the terms and conditions of this offer.
For questions about the program, including savings on mail-order prescriptions,
please call 1.855.439.2817.
Pharmacist Instructions for a Patient with an Eligible Third-party Payer:
When you redeem this card, you certify that you have not submitted and will not
submit a claim for reimbursement under any federal, state, or other government
programs for this prescription.
Submit the claim to the primary Third-party Payer first, then submit the balance due to
Change Healthcare using BIN #004682 as a Secondary Payer COB with
patient responsibility amount and a valid Other Coverage Code (eg, 8).
If you receive a rejection due to PA, step-edit, or NDC block, submit Other Coverage Code
of 3 (Secondary Claim). The patient’s out-of-pocket expense will be
reduced up to the maximum savings limit for the program. Reimbursement will be received
from Change Healthcare. For any questions regarding
Change Healthcare online processing, call the Help Desk at
Program managed by ConnectiveRx on behalf of Allergan.