Patient Savings and Education

Save on your LUPRON DEPOT co-pay*

The Lupron Depot Savings Card can help eligible, commercially insured patients pay as little as $10 for LUPRON DEPOT.*

Savings Card for patients with endometriosis

Savings card for patients with anemia related to uterine fibroids

Savings Card for patients with anemia prior to uterine fibroid surgery

To see if you qualify for a Savings Card, fill out the form below.

(Answers to all questions are required, unless otherwise noted.)

Select an indication

Endometriosis

Anemia prior to uterine fibroid surgery

Do you have private/commercial prescription insurance?

Yes

No

Are you enrolled in or are your prescriptions paid for in part or full under any state or federally funded prescription insurance program, such as Medicare (including Part D), Medicare Advantage, Medicaid, Medigap, The Department of Defense programs, Veterans Affairs, or TRICARE?

Yes

No

The LUPRON DEPOT Co-pay Savings Card is only available to patients with commercial prescription insurance coverage for LUPRON DEPOT. The LUPRON DEPOT Co-pay Savings Card is not available to patients receiving prescription drug coverage under any federal, state, or government-funded insurance program. If at any time you begin receiving prescription drug coverage under any federal, state, or government-funded program, you will no longer be eligible to participate in the LUPRON DEPOT Co-pay Savings Card Program and you may no longer use the LUPRON DEPOT Co-pay Savings Card.

I acknowledge and agree to the statement above and the eligibility below.

*Terms and Conditions apply. This benefit covers LUPRON DEPOT^® (leuprolide acetate for depot suspension). Eligibility: Available to patients with commercial insurance coverage for LUPRON DEPOT who meet eligibility criteria. Co-pay assistance program is not available to patients receiving reimbursement under any federal, state, or government-funded insurance programs (for example, Medicare [including Part D], Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs) or where prohibited by law or by the patient’s health insurance provider. If at any time a patient begins receiving drug coverage under any such federal, state, or government-funded healthcare program, patient will no longer be able to use the LUPRON DEPOT Co-pay Savings Card and patient must call LUPRON DEPOT at 1-855-587-7663 to stop participation. Patients residing in or receiving treatment in certain states may not be eligible. Patients may not seek reimbursement for value received from the LUPRON DEPOT Savings Program from any third-party payers. Offer subject to change or discontinuation without notice. Restrictions, including monthly maximums, may apply. Subject to all other terms and conditions, the maximum monthly benefit that may be available solely for the patient’s benefit under the co-pay assistance program is $300.00 per month during the calendar year for patients receiving LUPRON DEPOT every month or $600.00 per month during the calendar year for patients receiving LUPRON DEPOT every 3 months. The actual application and use of the benefit available under the co-pay assistance program may vary on a monthly, quarterly, and/or annual basis, depending on each individual patient’s plan of insurance and other prescription drug costs. This assistance offer is not health insurance. 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. To learn about AbbVie’s privacy practices and your privacy choices, visit https://abbv.ie/corpprivacy.

AbbVie Inc. reserves the right to rescind, revoke, or amend this offer without notice. LUPRON DEPOT is a registered trademark of AbbVie Inc. You may not combine this offer with any other rebate, coupon, free trial, or similar offer.

If your pharmacy isn't able to process your Savings Card for instant savings, you may still be eligible^† to get LUPRON DEPOT for as little as $10 per dose by receiving a rebate for the amount you paid out of pocket for your prescription. Simply download and fill out the Rebate Form, then mail it in or fax it to 1-908-548-0968, along with your pharmacy or treatment receipt.

Download Rebate Form

^†Eligibility: Available to cash-paying patients and patients with commercial prescription insurance coverage for LUPRON DEPOT (leuprolide acetate for depot suspension) and generic norethindrone acetate in the United States who meet eligibility criteria. This assistance program is not available to patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs (for example, Medicare [including Part D], Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs) or where prohibited by law or by the patient’s health insurance provider nor may patients seek reimbursement for any payments made for LUPRON DEPOT using any federal or state tax-exempt account (e.g., Health Savings Account, Flexible Spending Account, or Health Reimbursement Account). 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 able to use the LUPRON DEPOT Rebate and patient must call 1-855-587-76631-855-587-7663 to stop participation. Patients residing in or receiving treatment in certain states may not be eligible. Patients may not seek reimbursement for value received from this program from any third-party payers and assistance from this program may not be combined with any other rebate, coupon, free trial, or similar offer. Offer subject to change or discontinuance without notice. Restrictions, including monthly maximums, may apply. This is not health insurance.

Download brochures

Learn about LUPRON DEPOT for endometriosis.

Download brochure

Learn about LUPRON DEPOT for anemia prior to uterine fibroid surgery.

Download this educational brochure to learn about LUPRON DEPOT® for anemia related to uterine fibroids.

Download brochure

HCP Resources

Request LUPRON DEPOT 3.75 mg 1-Month Samples. If you have questions or experience any difficulty requesting samples, please reach out to AbbVie Sampler at: 1-833-999-17791-833-999-1779 or AbbViemsc_@knipper.com.

Request samples

Office Resources

Information and tools to help your patients access LUPRON DEPOT. AbbVie partners with two Hub Services Partners, RxCrossroads and AbbVie Insurance Specialist, to help streamline the LUPRON DEPOT and Add-back* procurement process.

5 easy steps to get your patients started:

1

Understand patient
benefits

Determine patient coverage
- Obtain both insurance cards
Medical card (managed care plan)
Prescription card (pharmacy benefits manager)
- If you are working with one of AbbVie's Hub Services partners, complete referral form and submit to RxCrossroads or AbbVie Insurance Specialist
Via fax or web-based provider portal
- RxCrossroads or AbbVie Insurance Specialist will provide the following information for each patient:
  - Patient benefits
  - Out-of-pocket costs
  - Specialty pharmacy
  - Prior Authorization requirements
If you are working directly with a patient's health insurance plan, pharmacy benefits manager, and/or specialty pharmacy, please be aware that each managed care plan has its own unique referral process and requirements to fill a prescription for a specialty drug. CoverMyMeds may be able to assist with this process by providing access to prior authorization forms for Medicare, Medicaid, Managed Medicaid, and commercial plans for LUPRON DEPOT and Add-back*

2

Coach patient on
what to expect

Discuss the process and timeline from prescription to injection
Help patient understand her out-of-pocket costs
- Deductibles may make out-of-pocket costs higher
- High-deductible plans may have lower monthly premiums but higher out-of-pocket deductibles
Encourage patient to download her LUPRON DEPOT^® or Add-back* Savings Card^†
Remind patient to respond promptly to calls from the specialty pharmacy or RxCrossroads, or AbbVie Insurance Specialist services, agree to delivery of medication, and provide payment
Reiterate importance of starting and staying on therapy
- Keeping the appointment for the first injection
- Continuing physician- or provider-directed treatment for the entire course of therapy

*Norethindrone acetate 5 mg daily.

^†Eligibility restrictions may apply. See LUPRON DEPOT or LUPRON DEPOT + Add-back* Savings Card for details.

3

Prepare prior
authorization and
clinical paperwork

Ensure you receive Prior Authorization (PA) form from RxCrossroads or AbbVie Insurance Specialist
- Even if using RxCrossroads, PA form may come from managed care plan, pharmacy benefits manager (PBM), or specialty pharmacy
- Ensure the correct form is received from managed care plan or PBM
Confirm all information is correct and complete, and sign the form
- Know the indication-based requirements and clinical criteria of the health plan
- Confirm rationale for use meets all plan criteria
- Gather required supporting information
RxCrossroads or AbbVie Insurance Specialist will direct you where to send the PA and supporting documentation on the Statement of Benefits
- Send a copy of PA and supporting documents to RxCrossroads or AbbVie Insurance Specialist

4

Respond promptly to
queries and denials

Promptly respond to all information requests to avoid delays
Investigate reasons for denials
- If denial letter received, ask service to investigate
- If reason for denial not provided, ask service to investigate
Gather required information needed to respond or appeal
Resubmit the completed, corrected, and signed documents to the requesting entity
Keep a log of all pending requests and need for follow-up with service

5

Secure approvals
and injections

Ensure RxCrossroads, AbbVie Insurance Specialist, MHC Plan, and/or Specialty Pharmacy has all necessary paperwork, such as referral or approved PA
Remind patient to respond to calls from specialty pharmacy or service, agree to delivery of medication, and provide payment
- Ensure that eligible patients use LUPRON DEPOT or LUPRON DEPOT + Add-back* Savings Card^†

*Norethindrone acetate 5 mg daily.

^†Eligibility restrictions may apply. See LUPRON DEPOT or Add-back* Savings Card for details.

Common criteria for PA approval for:

Endometriosis
LUPRON DEPOT or
LUPRON DEPOT
+ Add-back* therapy

criteria may vary by plan

1. A diagnosis of endometriosis

2. Initial treatment of endometriosis, not to exceed 6 months

3. Retreatment of endometriosis, not to exceed 6 months

4. Suspected endometriosis

5. Management of endometriosis, including pain relief. Reduction of endometriotic lesions for LUPRON DEPOT.

6. Endometriosis confirmed by laparoscopy and resistant to first-line treatment in females 18 years of age and older

7. Endometriosis not confirmed by laparoscopy when other potential causes have been excluded

*Norethindrone acetate 5 mg daily.

Anemia prior to
uterine fibroid surgery
LUPRON DEPOT ONLY

criteria may vary by plan

1. Diagnosis of fibroids

2. Diagnosis of anemia due to uterine fibroids, including previous treatment with iron therapy

3. Must be administered in conjunction with iron therapy

4. Preoperative hematologic improvement of patients with anemia due to heavy bleeding caused by uterine leiomyomata, preceded by a 1-month trial of iron therapy alone