Welcome to the LILETTA Patient Savings Program
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- Emil Alban Lang
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1 Welcome to the LILETTA Patient Savings Program Eligible insured patients, activate your card today* * See full program Terms and Conditions on page 3 of this brochure or at LILETTAcard.com.
2 Help With Your LILETTA Costs The LILETTA Patient Savings Program can help with the cost of LILETTA.* If you are an eligible commerciallyinsured patient, you may use the card to pay no more than $75 for LILETTA, up to a maximum savings limit of $500. What does the card cover? The card can help you with out-of-pocket costs for LILETTA over $75.* This card may only be used towards the cost of LILETTA itself. It does not cover the cost of insertion or other costs from your doctor s office. If you have any questions, please visit LILETTAcard.com or call * Eligible commercially-insured patients may pay no more than $75 for LILETTA up to a maximum savings limit of $500. Check with pharmacist or healthcare provider for copay discount. Patient out-of-pocket expense may vary. Offer not valid for patients enrolled in Medicare, Medicaid, or other federal or state healthcare programs. Program expires 9/30/15. Please see full program Terms and Conditions at 2
3 Am I Eligible for the Program? In order to participate in the LILETTA Patient Savings Program, patients must: 1. Have commercial health insurance 2. Not participate in Medicaid, Medicare, TRICARE, or any other federal or state healthcare program (including state pharmaceutical assistance programs) 3. Have an out-of-pocket expense for LILETTA that is greater than $75 4. Reside in the U.S. or Puerto Rico Please see below for the full Terms and Conditions of the LILETTA Patient Savings Program. Terms and Conditions: 1. This offer is valid only for commercially-insured patients and is good for use only with a LILETTA (levonorgestrel-releasing intrauterine system) 52 mg prescription at the time the prescription is filled or after the product is administered to the patient. 2. Depending on your insurance coverage, eligible insured patients may pay no more than $75 for LILETTA up to a maximum savings limit of $500. Check with your pharmacist or healthcare provider for your copay discount. Patient out-of-pocket expense may vary. 3. This offer is not valid for patients enrolled in Medicare, Medicaid, or other federal or state healthcare programs, or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this card if they are Medicare-eligible and enrolled in an employer-sponsored health plan or medical or prescription drug benefit program for retirees. 4. Each card is valid for one LILETTA prescription, which must be filled or administered to the patient before the program expires on 9/30/15. Savings requests must be submitted to or faxed to within 60 days after the prescription is filled and the product is administered to the patient. 5. Actavis reserves the right to rescind, revoke, or amend this offer without notice. 6. Offer good only in the USA, including Puerto Rico, at participating pharmacies or healthcare providers. 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 expires September 30, By redeeming this card, you acknowledge that you are an eligible insured patient and that you understand and agree to comply with the terms and conditions of this offer. LILETTA may be covered under your plan s medical or pharmacy benefit. 3
4 Using the LILETTA Patient Savings Program To get started, activate your card at LILETTAcard.com or by calling Now, your card can be used if: You receive an Explanation of Benefits (EOB) form The EOB will let you know how much you owe your doctor s office for LILETTA. Use the steps on the opposite page for help with LILETTA costs over $75.* You are contacted by a Specialty Pharmacy A representative from a Specialty Pharmacy may contact you. If asked about payment, provide your card number (example: LILXXXXXXXX) and the Rx BIN# found on the card. If you have already paid for LILETTA in full at the time of insertion, visit LILETTAcard.com for rebate instructions.* * A maximum savings limit of $500 applies. The first $75 plus any remaining balance must be paid after the maximum savings limit for the program is reached. Savings can only be used towards the cost of the LILETTA product itself. 4
5 Submitting Your EOB for LILETTA Step 1: Submit your EOB You can submit your EOB to LILETTAcard.com or fax it to A confirmation will be sent to the address or fax number used Step 2: LILETTAcard.com will load your card After 2 business days, you will receive another confirmation by or fax. This will let you know if your card has been loaded or if we require additional information Step 3: Use your card to pay for LILETTA* Your card can now be used to pay for LILETTA.* Just give your doctor s office the 16-digit card number Please note that you are responsible for the first $75 spent for LILETTA* The EOB must include the Insurance Carrier, Date of Service, Product Name/ J-code, and Patient Responsibility. All confirmation messages will be sent to the address or fax number that was used to submit the EOB unless you provide alternate contact information. 5
6 Answers to Your Questions What if I receive a call from a Specialty Pharmacy? A representative from a Specialty Pharmacy may contact you about your LILETTA payment. Make sure to provide the card number (example: LILXXXXXXXX) and the Rx BIN# listed on your card. Does the card help cover the cost of my doctor s visit or LILETTA insertion? No, the card only covers the cost of the LILETTA product itself. What happens if I lose my card? You can call between 9 am 5 pm EST (Monday through Friday) to obtain your account number over the phone. What if I already paid for LILETTA in full? If you paid your financial responsibility for LILETTA in full at the time of insertion, visit LILETTAcard.com to download a rebate request form. Once completed, submit your rebate request form along with your EOB to LILETTAcard.com or via fax at for a rebate. Once you have received your rebate, the card will no longer be necessary. 6
7 Your Card Use the card below when paying for LILETTA. This card requires activation. Please visit or call Eligible commercially-insured patients may pay no more than $75 for LILETTA up to a maximum savings limit of $500. Check with pharmacist or healthcare provider for copay discount. Patient out-of-pocket expense may vary. Offer not valid for patients enrolled in Medicare, Medicaid, or other federal or state healthcare programs. Program expires 9/30/15. See full program Terms and Conditions on page 3 of this brochure or at By using this card, you understand and agree to comply with the full Terms and Conditions of this offer. 7
8 We re here to help. Visit LILETTAcard.com or call for additional support. Please see accompanying full Prescribing Information. LILETTA and its design are trademarks of Odyssea Pharma SPRL, an Actavis affiliate Actavis Pharma, Inc., Parsippany, NJ All rights reserved. LLT /15 Printed in the USA.
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