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PHEXXI® SAVINGS PROGRAM



WELCOME TO THE PHEXXI SAVINGS PROGRAM


ELIGIBLE WOMEN MAY PAY $0 FOR THEIR FIRST PRESCRIPTION AND AS LITTLE AS $25 FOR
REFILLS

See program Terms, Conditions, and Eligibility Criteria.

Please see full Prescribing Information for Phexxi, including Patient
Information.

Depending on your insurance coverage, eligible patients may pay $0 for their
Phexxi prescriptions. Check with your pharmacist for your copay discount.
Maximum savings limits apply; patient out-of-pocket expense will vary. Offer not
valid for patients enrolled in Medicare, Medicaid, other federal or state
healthcare programs, or where prohibited by law. See program Terms, Conditions,
and Eligibility Criteria.


YOU MAY BE ELIGIBLE FOR SAVINGS. SIGN-UP IS EASY. START NOW!




PLEASE TELL US ABOUT YOURSELF

*Required Field.

FIRST NAME*
Please enter First Name.
LAST NAME*
Please enter Last Name.
EMAIL ADDRESS*
Please enter a valid email.
ZIP CODE
 

By providing your email address above, you agree and acknowledge that you would
like to receive email communications from Evofem related to Phexxi Program,
including refill reminders, etc. The information pertaining to you that we
collect will be used in accordance with our Privacy Statement. If you later wish
to stop receiving certain communications, you may unsubscribe by clicking on the
link provided in future emails.
Please agree to this statement to participate in this program.



PLEASE ANSWER THE FOLLOWING QUESTIONS

Do you live in the United States or Puerto Rico?
Yes
No
Please select Yes or No.
Do you have commercial prescription drug insurance? (If you have Medicaid,
Medicare, or other government-sponsored prescription insurance, such as VA/DOD,
select “No”)
Yes
No
Please select Yes or No.

By activating your Phexxi Savings Offer, you certify that you are not enrolled
in a federal government- or state government-funded prescription drug benefit
program, such as Medicare, Medicaid, or any private indemnity or HMO insurance
plan that reimburses you for the entire cost of your prescription drugs. You
also certify that you are not Medicare-eligible and enrolled in an
employer-sponsored health plan or prescription drug benefit program for
retirees. You further certify that should you begin receiving prescription
benefits from one of these types of programs at any time, you will no longer
participate in this savings programs.


I agree to this certification, and I have read and accept the program Terms,
Conditions, and Eligibility Criteria.
Please agree to this statement to participate in this program.

IF YOU HAVE ANY QUESTIONS ABOUT THE PHEXXI SAVINGS PROGRAM, PLEASE CALL
1-855-358-6583.

Submit





INDICATION

Phexxi® is an on-demand method of birth control used to prevent pregnancy.
Phexxi is not effective when used after sex.

IMPORTANT SAFETY INFORMATION

Rare cases (0.36%) of bladder and kidney infection have been reported. If you
have a history of urinary tract problems that keep coming back, you should not
use Phexxi.

Contact your healthcare provider if you are experiencing genitourinary side
effects such as vaginal burning, itching, discharge, genital discomfort
(including in male partners), yeast infection, urinary tract infection or
bacterial vaginosis.

Phexxi does not protect against any sexually transmitted infections, including
HIV. Avoid using Phexxi with a vaginal ring.

Avoid Phexxi if you or your sexual partner is allergic to lactic acid, citric
acid, potassium bitartrate, or any of the ingredients in Phexxi. Stop using
Phexxi if you develop an allergic reaction.

For more information about Phexxi, talk to your healthcare provider and see full
Product Information.

Please report side effects by contacting Evofem Biosciences® toll-free at
1-833-EVFMBIO or contact FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

Phexxi and the Phexxi logo are registered trademarks of Evofem Biosciences, Inc.
Trademarks, registered or otherwise, are the property of their respective
owner(s).

 * © 2022 Evofem Biosciences, Inc.
 * EVFM-US-001897
 * January 2022

INDICATION

Phexxi® is an on-demand method of birth control used to prevent pregnancy.
Phexxi is not effective when used after sex.

IMPORTANT SAFETY INFORMATION

Rare cases (0.36%) of bladder and kidney infection have been reported. If you
have a history of urinary tract problems that keep coming back, you should not
use Phexxi.


PHEXXI SAVINGS OFFER TERMS AND CONDITIONS

X

Terms and Conditions: This offer is not valid for any patient where
prescriptions are paid for in part or full by any state or federally funded
programs, including but not limited to Medicare, Medicaid, Medigap, VA, DOD,
TRICARE, or by private health benefit programs which reimburse for the entire
cost of prescription drugs. This card is not valid for patients who are Medicare
eligible and are enrolled in an employer-sponsored health plan or prescription
drug benefit program for retirees (i.e., patients who are eligible for Medicare
Part D but receive a prescription drug benefit through a former employer). Cash
Discount Cards and other non-insurance plans are not valid as primary under this
offer. If the patient is eligible for drug benefits under any such program, the
patient cannot use this offer. By redeeming this offer, the patient and the
pharmacist acknowledge that the patient is eligible, and the patient and
pharmacist understand and agree to comply with the Terms and Conditions of this
offer.

To the Patient: Eligible patients may pay $0 for their first Phexxi prescription
and pay as little as $25 for refills. In order to redeem this offer you must
have a valid prescription for Phexxi. Follow the dosage instructions given by
the doctor. 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 Phexxi Savings offer should call 1-855-358-6583.

To the 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. 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: 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). Valid
Other Coverage Code required. For any questions regarding Change Healthcare
online processing, please call the Help Desk at 1-800-433-4893.

Restrictions: This offer is valid in the United States. Offer not valid for
prescriptions reimbursed under Medicaid, a Medicare drug benefit plan, Tricare
or other federal or state health programs (such as medical assistance programs).
Cash Discount Cards and other non-insurance plans are not valid as primary under
this offer. If the patient is eligible for drug benefits under any such program,
the patient cannot use this offer. By using this offer, the patient certifies
that he or she will comply with any terms of his or her health insurance
contract requiring notification to his or her payor of the existence and/or
value of this offer. It is illegal to (or offer to) sell, purchase, or trade
this offer. Program expires 12/31/2022. This offer is not transferable and is
limited to one offer per person. Not valid if reproduced. Void where prohibited
by law. Program managed by ConnectiveRx on behalf of Evofem Biosciences. The
parties reserve the right to rescind, revoke or amend this offer without notice
at any time.



×


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