ELIGIBLE PATIENTS MAY
PAY AS LITTLE AS
PER 1-MONTH OR 3-MONTH
You may be eligible† for savings.
Sign-up is easy. Start now!
†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 healthcare programs. See Program Terms, Conditions, and Eligibility Criteria.
Based on the information you have provided, you are not eligible to participate in this program.
Thank you for your interest.
If you are a patient and have questions about the program, including savings on mail-order prescriptions, please call 1.855.439.2817.
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 the Allergan Savings Program Navigator at 1.800.769.3161.
Program managed by ConnectiveRx on behalf of Allergan.
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