1. This offer is good for use only with a valid prescription for ANNOVERA (segesterone acetate and ethinyl estradiol) vaginal system at the time the prescription is filled by the pharmacist and dispensed to the patient.
2. During the active date of the savings program (Program), eligible patients may pay as little as $60 for one 12 month vaginal system.
3. Maximum annual savings limit of up to $720 may apply based on patient’s individual insurance plan rules and patient’s deductible; therefore, patient’s out-of-pocket expense may vary.
4. This offer is valid only for commercially insured patients with ANNOVERA coverage.
5. This offer is not valid for use by patients enrolled in Medicare, Medicaid, or other federal or state programs (including any state pharmaceutical assistance programs), or private indemnity or HMO Insurance plans that provide any coverage for ANNOVERA.
6. Void outside the United States and its territories or where prohibited by law, taxed, or restricted.
7. This Program is not health insurance, redeemable for cash, or transferable, and is not valid with any other offer.
8. TherapeuticsMD (the Company) reserves the right to amend or end this program at any time without notice. Data related to the patient's redemption with this co-pay savings card may be collected, analyzed, and shared with the Company for market research and other purposes related to assessing coupon and rebate programs. Any data will be aggregated and de-identified.
9. By redeeming this co-pay savings card, you acknowledge that you meet the eligibility criteria and that you understand and agree to comply with the terms and conditions of this offer.
For questions about this Program please call 1-888-228-2560.
Authorization to Contact
I understand and consent to TherapeuticsMD contacting me using the information provided in this form to enroll me in, operate, and administer TherapeuticsMD's patient support services and/or programs as described. I understand TherapeuticsMD and its affiliated companies may use my information to check my active insurance benefits, conduct market research, send other marketing communications and information via phone, email, text and push notification in their apps.
Pharmacist Instructions for a patient with an eligible third-party payer: 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.