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Savings on LILETTA

Eligible patients pay $100, then save up to a maximum
of $700, for the LILETTA product.*

Eligible patients pay $100, then save up to a maximum of $700, for the LILETTA product.*

Submit your forms for a previous application here.

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For patients who do not have a card

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For patients who have received
their card

For patients who have received their card

Rebate request

For patients who have paid
for LILETTA

For patients who have paid for LILETTA

If you are a patient who had LILETTA inserted on or before 10/31/2018, and wish to enroll in the LILETTA Patient Commitment Program, please click here.

Submit your forms for a previous application here.

^*Depending on insurance coverage, eligible patients pay $100, then save up to a maximum of $700, for the LILETTA^® product. Offer applies to product only, and does not apply to costs associated with medical examination or product administration. Check with your pharmacist or healthcare provider for your 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 10/31/19. Please see full LILETTA Patient Savings Program^® Terms, Conditions, and Eligibility Criteria here.

^†Depending on insurance coverage, eligible patients who received their first LILETTA on or before October 31, 2018 may have their out-of-pocket cost for a second LILETTA reduced to $0, up to a maximum savings limit of $700. Offer applies to product only, and does not apply to costs associated with medical examination or product administration. 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. Please see LILETTA + LILETTA Patient Commitment Program^® Terms and Conditions here.

1. This offer is good for use only by eligible patients who received their first LILETTA on or before October 31, 2018 and who have a valid prescription for a second LILETTA, at the time the second prescription is filled or after the second LILETTA is administered to the patient. 2. Depending on your insurance coverage, eligible patients wishing to continue with LILETTA may have their out-of-pocket cost reduced to $0 for a second LILETTA, up to a maximum savings limit of $700. Offer applies to product only, and does not apply to costs associated with medical examination or product administration. 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 who, at the time they received their first or second LILETTA, were 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 offer if, at the time they received their first or second LILETTA, they were Medicare-eligible and enrolled in an employer-sponsored health plan or medical or prescription drug benefit program for retirees. This offer is also not valid for patients who were cash-paying patients at the time they received their first or second LILETTA. 4. This offer is valid for one LILETTA prescription, which must be for a second LILETTA for a patient wishing to continue with LILETTA, and must be filled or administered to the patient before the program expires on 10/31/22. Patients must enroll at LILETTAcard.com or by calling 1-855-706-4508 within 60 days after receiving their first LILETTA, providing Explanation of Benefits (EOB) documentation. Savings requests and required EOB documentation for the second LILETTA must be submitted to LILETTAcard.com or faxed to 1-888-683-4991 within 60 days after the second LILETTA prescription is filled and the second LILETTA is administered to the patient. 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 pharmacies or healthcare providers. 7. Void where prohibited by law, taxed, or restricted. 8. This offer is not transferable. The selling, purchasing, trading, or counterfeiting of this card 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. This offer is not health insurance. 11. This offer expires October 31, 2022. 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.

For assistance, please call 1-855-706-4508 Monday through Friday 9 AM—8 PM (except holidays).

Program managed by ConnectiveRx on behalf of Allergan.

Indication

LILETTA^® (levonorgestrel-releasing intrauterine system) 52 mg is a hormone-releasing system placed in your uterus to prevent pregnancy for as long as you want for up to 5 years.

Important Risk Information About LILETTA

Do not use LILETTA if you:
- Are or might be pregnant; LILETTA cannot be used as an emergency contraceptive
- Have a serious pelvic infection called pelvic inflammatory disease (PID) or endometritis unless you have had a normal pregnancy after the infection went away (PID occurs in less than 1% of users)
- Have an untreated lower genital infection now
- Have had an infection from an abortion within the last 3 months
- Can get infections easily; for example, if you:
  - Have problems with your immune system
  - Have multiple sexual partners or your partner has multiple sexual partners
  - Use or abuse intravenous drugs
- Have or suspect you might have cancer of the uterus or cervix
- Have bleeding from the vagina that has not been explained
- Have short-term (acute) liver disease or liver tumor
- Have breast cancer or any other cancer that is sensitive to progestin (a female hormone), now or in the past
- Have an intrauterine system (IUS) in your uterus already
- Have a condition of the uterus that changes the shape of the uterine cavity, such as large fibroid tumors
- Are allergic to levonorgestrel, silicone, polyethylene, or barium sulfate
Call your healthcare provider right away if you think you are pregnant. If you get pregnant while using LILETTA, you may have an ectopic pregnancy, which means the pregnancy is not in the uterus. Unusual vaginal bleeding or abdominal pain especially with missed periods may be a sign of ectopic pregnancy. Ectopic pregnancy can cause internal bleeding. There are also risks if you get pregnant while using LILETTA and the pregnancy is in the uterus. Severe infection and premature labor or delivery can occur with pregnancies that continue with an IUS
Although uncommon, pregnancy while using LILETTA can be life threatening and may result in loss of pregnancy or fertility
Bleeding and spotting may increase in the first 3 to 6 months and remain irregular. Periods over time usually become shorter, lighter or may stop
Life-threatening infection can occur within the first few days after LILETTA is placed. Call your healthcare provider immediately if you develop severe pain or fever shortly after LILETTA is placed
Some IUS users get a serious pelvic infection called pelvic inflammatory disease (PID) or endometritis. These are usually sexually transmitted. You have a higher chance of getting PID or endometritis if you or your partner has sex with other partners. PID or endometritis can cause serious problems such as infertility, ectopic pregnancy or pelvic pain that does not go away. More serious cases of PID or endometritis may require surgery. Removal of the uterus (hysterectomy) is sometimes needed. In rare cases, infections that start as PID or endometritis can even cause death. Tell your healthcare provider right away if you have any of these signs of PID or endometritis: long-lasting or heavy bleeding, unusual vaginal discharge, low abdominal pain, painful sex, chills, or fever
LILETTA may become attached to (embedded) or go through the uterus (perforation). If perforation occurs, LILETTA may move outside the uterus and can cause internal scarring, infection, or damage to other organs and you may need surgery to have LILETTA removed. Risk of perforation is increased in breastfeeding women
LILETTA may come out of your uterus (expulsion). Expulsion occurs in about 4 out of 100 women, most often in the first year of use. You may become pregnant if LILETTA comes out. If you think that LILETTA has come out, use another birth control method like condoms and spermicide or do not have sex (vaginal intercourse) until you are seen by a healthcare provider
Ovarian cysts may occur but usually disappear

LILETTA does not protect against HIV or STDs.

Available by prescription only.

Please see full Prescribing Information.

Reference: 1. LILETTA (levonorgestrel-releasing intrauterine system) 52 mg [Prescribing Information]. Irvine, CA: Allergan and Medicines360; 2018.

LILETTA Patient Saving Program®

LILETTA + LILETTA Patient Commitment Program®

LILETTA
Patient Saving Program^®

LILETTA + LILETTA
Patient Commitment Program^®