Lo Loestrin Fe Savings Program

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Based on the information provided, you are not eligible to participate in this program. Thank you for your interest.

First name*

Last name*

ZIP code*

Date of birth (mm/dd/yyyy)*

Email address*

Your email will be used only to provide assistance with this program.

By providing your email address above, you agree and acknowledge that you would like to receive email communications from AbbVie related to Lo Loestrin Fe and the Lo Loestrin Fe Savings Program, including site updates, patient education, as well as other AbbVie products and services. The categories of personal information collected in this form include name, date of birth and email address. The personal information collected will be used for program management and to perform research and analytics on a de-identified basis. For more information about the categories of personal information collected by AbbVie and the purposes for which AbbVie uses personal information, visit Privacy Notice.

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I agree, and I certify that the information I have provided about myself is complete and accurate.*

Please answer the following questions:

Do you live in the United States or Puerto Rico?*

Yes

Do you have commercial prescription drug insurance? (If you have Medicaid, Medicare, or other government-sponsored prescription insurance, such as VA/DOD, select “No”.)*

Yes

By activating your Lo Loestrin® Fe Savings Offer, you certify that you are not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare, Medicaid, or any private indemnity or HMO insurance plan that reimburses you for the entire cost of your prescription drugs. You also certify that you are not Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. You further certify that should you begin receiving prescription benefits from one of these types of programs at any time, you will no longer participate in this savings program.

I agree to this certification, and I have read and accept the Lo Loestrin Fe Savings Program Full Terms and Conditions below.*

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^†Lo Loestrin Fe Savings Program Full Terms and Conditions

1. This offer is available to patients with commercial prescription insurance coverage and a valid prescription for Lo Loestrin^® Fe (norethindrone acetate and ethinyl estradiol tablets, ethinyl estradiol tablets and ferrous fumarate tablets) and is good for use at the time the prescription is filled by the pharmacist and dispensed to the patient. 2. This offer is not valid for use by patients enrolled in Medicare, Medicaid, or other federal or state healthcare programs (including any state pharmaceutical assistance programs); private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs; or health insurance plans that prohibit use of this offer. 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. If at any time, a participating patient begins receiving prescription drug coverage under any federal, state, or government-funded healthcare program, that patient will no longer be eligible for and will cease using this program. 3. Depending on insurance coverage eligible patients whose insurance covers Lo Loestrin Fe, may pay as little as $25 for each of up to thirteen (13) prescription fills of a 28-day supply OR each of up to four (4) prescription fills of an 84-day supply. Eligible patients whose insurance does not cover Lo Loestrin Fe, or where coverage restrictions have not been satisfied, may pay as little as $30 for each of up to thirteen (13) prescription fills of a 28-day supply, OR $70 for each of up to four (4) prescription fills of an 84-day supply. Check with your pharmacist for your co-pay discount. Maximum savings limits apply; patient out-of-pocket expense will vary. 4. AbbVie reserves the right to rescind, revoke, or amend this offer without notice. 5. Offer good only in the USA, including Puerto Rico, at participating retail pharmacies. Patients residing in or receiving treatment in certain states may not be eligible to participate in this program. 6. Void if prohibited by law, taxed, or restricted. 7. Patients may not seek reimbursement for value received under the Lo Loestrin Fe Savings Program from any third-party payers. 8. This offer is not transferable. The selling, purchasing, trading, or counterfeiting of this offer is prohibited by law. 9. This offer 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. 10. Subject to all other terms and conditions, the maximum benefit that may be available solely for the patient’s benefit under the savings program is up to $146 for a 28-day supply and up to $240 for an 84-day supply for patients whose insurance covers Lo Loestrin Fe. The actual application and use of the benefit available under the savings program may vary on a monthly, quarterly, and/or annual basis depending on each individual patient’s plan of insurance (including whether coverage for Lo Loestrin Fe is available) and other prescription drug costs. 11. This offer is not health insurance. 12. By redeeming this offer, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer. 13. To learn about AbbVie’s privacy practices and your privacy choices, visit https://privacy.abbvie.

If you have any questions about the Lo Loestrin^® Fe Savings Program, please call 1.855.439.2817.

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Password Resets, Login, Profile, Representative, Contact Us, Polls, Social Share, Doctor Discussion Guide, Dosing Guide, Symptom Checker, Knowledge Assessment, Event, More Info, Sign Up, Saving Card, Benefit Verification, Benefit Enrollments, Medical Exception, Injection Form, Share a Story

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