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ARE YOU IN THE Lo?

Program Terms, Conditions and Eligibility Criteria:

1. 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.

2. 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.

3. 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.

4. 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 12/31/20.

5. Allergan reserves the right to rescind, revoke, or amend this offer without notice.

6. Offer good only in the USA, including Puerto Rico, at participating retail pharmacies.

7. Void if prohibited by law, taxed, or restricted.

8. This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law.

9. 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.

10. This offer is not health insurance.

11. This card expires December 31, 2020.

12. 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.

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 03 (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 Allergan Savings Program Navigator at 1.800.769.3161.1.800.769.3161.

Program managed by ConnectiveRx on behalf of Allergan.