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Follow the LILETTA Patient Savings Program^®^* application steps below:

Step 1: Patient Information Release

STEP 1: Patient Information Release

In order to participate in the LILETTA Patient Savings Program^®, you must meet certain eligibility criteria. During the enrollment process for the program, you will be asked to provide personal information, such as your name, address, phone number, email address, and information related to your insurance and treatment. The information pertaining to you that we collect will be used in accordance with the AbbVie Privacy Statement, which can be found at www.AbbVie.com/privacy.

By enrolling in the LILETTA Patient Savings Program^®, you agree that you would like to receive and that AbbVie and its affiliates and vendor partners may contact you with information related to LILETTA^® and the LILETTA Patient Savings Program^®, including site updates, education, and other AbbVie products, services, and programs. You may choose to be contacted by mail or email. If you later wish to opt out of receiving this information, you may cancel your enrollment in this program at any time by calling 1.855.706.4508.

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^*Depending on insurance coverage, eligible patients pay $100, then save up to a maximum of $750, for the first 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 06/30/2022. Please see full LILETTA Patient Savings Program^® Terms, Conditions, and Eligibility Criteria here.

This offer is available to patients with commercial prescription insurance coverage for a valid prescription of LILETTA^® (levonorgestrel-releasing intrauterine system) 52 mg prescription at the time the prescription is filled or after the product is administered to the patient.
This offer is not valid for patients enrolled in Medicare, Medicaid, or other federal or state healthcare 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 medical or prescription drug benefit program for retirees. This offer is not valid for cash-paying patients. If at any time a patient begins receiving prescription drug coverage under any such federal, state or government-funded healthcare program, patient will no longer be eligible to use the LILETTA^® Patient Savings Program.
Depending on your insurance coverage, eligible patients pay $100, then save up to a maximum of $750 for the first LILETTA^® product. Check with your pharmacist or healthcare provider for your copay discount. Patient out-of-pocket expense may vary.
Each card is valid for one LILETTA^® prescription, which must be filled or administered to the patient before the program expires on 06/30/2022. 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.
AbbVie reserves the right to rescind, revoke, or amend this offer without notice.
Offer good only in the USA, including Puerto Rico, at participating pharmacies or healthcare providers. Patients residing in or receiving treatment in certain states may not be eligible.
Void where prohibited by law, taxed, or restricted.
Patients may not seek reimbursement for value received from LILETTA^® Savings Program from any third-party payers.
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.
This offer is not health insurance.
This card expires June 30, 2022.

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 AbbVie.

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 6 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 San Francisco, CA: Medicines360; 2020.

LILETTA Patient Saving Program®

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Step 1: Patient Information Release

LILETTA
Patient Saving Program^®

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