If you have previously started enrollment for the LILETTA Patient Savings Program®* (application or rebate request) and have yet to supply the required forms, you can upload them now. Download rebate request form here. You can also submit your EOB within 180 days of insertion if you do not have your EOB at the time of enrollment. Simply return to LILETTAcard.com to upload your EOB when you receive it.
1. This offer 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 patients pay $100, then save up to a maximum of $750, for the LILETTA® product. 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 offer if they are Medicare-eligible and enrolled in an employer-sponsored health plan or medical or prescription drug benefit program for retirees. This offer is not valid for cash-paying patients. 4. Each card is valid for one LILETTA® prescription, which must be filled or administered to the patient before the program expires on 6/30/2021. Savings requests and required supporting documentation must be submitted to www.LILETTAcard.com or faxed to 1.888.683.4991 within 180 days after the prescription is filled and the product 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 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 June 30, 2021. 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.
For patient assistance, please call 1.855.706.4508 Monday through Friday 9 AM—8 PM ET (except holidays). For healthcare provider or pharmacist assistance, please call the 24 hr/7 day a week help desk at 1.866.242.9104.
Program managed by ConnectiveRx on behalf of Allergan.
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 6 years.
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 San Francisco, CA: Medicines360; 2019.