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.

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I consent to the collection, use, and disclosure of my health-related personal data and/or precise geolocation personal data to receive communications from AbbVie regarding its products, programs, services, clinical trials, research opportunities and for online targeted advertising, as further described in the “How we may use Personal Data,” “How we disclose Personal Data,” and “Cookies and similar tracking and data collection technologies” sections of our Privacy Notice. My consent is required to process sensitive personal data under certain privacy laws, and I have the right to withdraw my consent by visiting “Your Privacy Choices” on AbbVie’s website.

AbbVie may collect your personal data through your online and offline interactions with us, including your contact data, geolocation, and health-related data...

...We may also collect your online usage data automatically through cookies and similar technologies. We use this information for several purposes, such as to provide you with, administer, and improve our programs, services and products, customize your experiences, and for research and analytics. We retain your personal data for as long as necessary to fulfill these purposes or to comply with our record retention obligations. We do not sell your personal data, but may use and disclose your personal data with marketing and advertising partners to deliver you ads based on your interests inferred from your activity across other unaffiliated sites and services (“online targeted advertising”) and for website analytics. To opt out of the use or disclosure of your personal data for online targeted advertising or for website analytics, go to Your Privacy Choices on our website. For more information on the personal data categories we collect, the purposes for their collection, disclosures to third parties, and data retention, visit our Privacy Notice.

Through my submission of the Registration Form, I consent to the collection, use, and disclosure of my personal health data, as described in the Privacy Notice above and in AbbVie’s Privacy Notice in the “How We May Disclose Personal Data” section. My consent is required to process sensitive personal data under certain privacy laws, and I have the right to withdraw my consent by visiting “Your Privacy Choices” on AbbVie’s website.

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 $154 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://abbv.ie/corpprivacy

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

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Form Category:

Account Management, Contact, Interactions, Quiz, Registration, Services

Form Sub-Category:

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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Form MVA Category:

Savings Card, Insurance, Symptom Journal, Test Score Tracker, Condition Information, Doctor Discussion Guide, Dosing Information, Enrollment Form, Flashcard, Medical Exception, Patient Counseling Guide, Savings Card, Symptom Journal, Doctor Discussion Guide, Doctor Search, Dosage Calculator, Enroll, Med Reminders, Quick Poll, Resource Request, Symptom Quiz, UGC Submission, Contact Rep, Savings Card, Social Share, App Store, More Info, Patient Resources, Share Information, Share Results, Submit a Story, Assessment Tool, Benefits Verification, Carousel, Initiation, Myth versus Fact, Workaround Quiz, Formulary Tool, Image Expand, Medical Exception, Q And A, Slider, Administration Instructions, Condition Information, Insurance, Inventory, Mechanism of Action, Patient Story, Product Overview, Program Overview, Injection Training, Other

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