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

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FIRST NAME*

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LAST NAME*

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EMAIL ADDRESS*

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ZIP CODE

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.

PHEXXI SAVINGS OFFER TERMS AND CONDITIONS

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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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