Patient Savings and Education

Save on your LUPRON DEPOT co-pay*

If you and your doctor are discussing the use of LUPRON DEPOT, or if you have already started treatment, you may be eligible for savings on your prescription co-pay.*

You could pay as little as

^$10

toward your out-of-pocket cost per dose of LUPRON DEPOT

You
save
up to

^$125

for 1-month 3.75-mg dose

You
save
up to

^$250

for 3-month 11.25-mg dose

Savings Card for patients with endometriosis

Savings Card for patients with anemia prior to uterine fibroid surgery

Savings card for patients with anemia related to uterine fibroids

If your pharmacy isn't able to accept this savings card and provide instant savings, eligible patients* can receive the savings by downloading the rebate form to print and mail, along with your pharmacy or treatment receipt and a copy of the front of your Savings Card.

Download rebate form

*Eligibility: Available to patients in the United States with commercial prescription insurance coverage for LUPRON DEPOT® (leuprolide acetate for depot suspension) and generic norethindrone acetate who meet eligibility criteria. Co-pay 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 Veteran’s Affairs programs) or where prohibited by law or by the patient’s health insurance provider. 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® card 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 card from any third-party payers. Offer subject to change or discontinuance without notice. Restrictions, including monthly maximums, may apply. This is not health insurance.

Good for out-of-pocket expenses up to $125 on your 3.75 mg LUPRON DEPOT prescription after the initial $10 co-pay or up to $250 on your 3-Month 11.25 mg LUPRON DEPOT prescription after the initial $10 co-pay. 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.

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

Office Resources

Information and tools to help your patients access LUPRON DEPOT. AbbVie partners with two Hub Services Partners, RxCrossroads and Pharmacy Solutions, 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 Pharmacy Solutions
Via fax or web-based provider portal
- RxCrossroads or Pharmacy Solutions 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 Pharmacy Solutions 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 Pharmacy Solutions
- Even if using RxCrossroads or 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 Pharmacy Solutions 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 Pharmacy Solutions

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, Pharmacy Solutions, MHC Plan, and/or Specialty Pharmacy has all necessary paperwork, such as referral, 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