MOST COMMERCIALLY INSURED PATIENTS

PAY AS LITTLE AS $25*

Restrictions Apply. Please see below for Terms and Conditions.

Eligible patients can save up to $70 on each Evamist ® applicator*. Fill out the following form below to see if you are eligible. See below for Terms and Conditions. Individuals enrolled in federal or state prescription insurance programs are not eligible. Certain other restrictions apply.

*Eligible patients will pay the first $25 and receive up to $70 off the patient’s co-pay or out-of-pocket expenses for each applicator.

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TERMS AND CONDITIONS
Patient Instructions: In order to redeem this offer you must have a valid prescription for Evamist ® (estradiol transdermal spray). and you may not be enrolled in a state or federally funded prescription benefit program, including, but not limited to, Medicare, Medicaid, Veterans Affairs (VA), Department of Defense (DOD), or TRICARE. This offer may not be redeemed for cash. By using this offer, you are certifying that you meet the eligibility criteria and will comply with the terms and conditions described in the Restrictions section below. Patients with questions about the offer should call 1-844-415-0672.

Pharmacist: When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental programs for this prescription and will not seek reimbursement from health insurance or any third party for any part of the benefit the patient receives through this program. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. By participating in this program, you are certifying that you will comply with the terms and conditions described in the Restrictions section below.

Pharmacist instructions for a patient with an Eligible Third Party Payer: Submit the claim to the primary Third Party Payer first, then submit the balance due to CHANGE HEALTHCARE as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code, (e.g. 8). The patient is responsible for the first $25 and the card pays up to the next $70 on each applicator. The patient is responsible for any remaining balance. Reimbursement will be received from CHANGE HEALTHCARE .

Pharmacist instructions for a cash paying patient: Submit this claim to CHANGE HEALTHCARE . A valid Other Coverage Code (e.g. 1) is required. The patient is responsible for the first $25 and the card pays up to the next $70 on each applicator. The patient is responsible for any remaining balance. Reimbursement will be received from CHANGE HEALTHCARE .

Valid Other Coverage Code required. For any questions regarding CHANGE HEALTHCARE online processing, please call the Help Desk at 1-800-422-5604.

Restrictions: This offer is valid in the United States. Offer not valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan, VA, Tricare or other federal or state health programs (such as medical assistance programs). If the patient is eligible for drug benefits under any such program or is Medicare eligible and enrolled in employer-sponsored group waiver health plans or government-subsidized prescription drug benefit programs for retirees, the patient cannot use this offer. By using this offer, the patient and pharmacist certify that they will comply with any terms or requirements imposed on patients or providers by the health insurance to notify the health insurance plan of the existence and/or value of this offer. Offer not valid for patients under 18 years of age. It is illegal to (or offer to) sell, purchase, or trade this offer. This offer is not transferable and is limited to one offer per person. Not valid if reproduced. Void where prohibited by law. This is not insurance. Program managed by ConnectiveRx, LLC. on behalf Perrigo Company of South Carolina, Inc. The parties reserve the right to rescind, revoke or amend this offer without notice at any time.

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