With this Savings Offer, you may pay as little as $0 for each monthly prescription fill of Gwyn Lo (norelgestromin and ethinyl estradiol transdermal system) 220/20 mcg per day, while this program remains in effect. Your out-of-pocket costs will vary depending on your insurance coverage and are subject to program limits, including maximum quantity and maximum aggregate savings cap amounts per patient per calendar year. No other purchase is necessary. Valid prescription with Prescriber ID# is required. Viatris Specialty LLC reserves the right to amend or end this program at any time without notice.

If you are a commercially insured patient with coverage for Gwyn Lo, this Savings Offer may be used to reduce the amount of your out-of-pocket costs for Gwyn Lo up to a maximum of $175 per 28-day prescription, while this program remains in effect. 

If you are a commercially insured patient without coverage for Gwyn Lo or are an uninsured patient and paying cash, you may pay as little as $40 per 28-day prescription, and as little as $65 per 84-day prescription of Gwyn Lo with this Savings Offer, while this program remains in effect. 

Eligibility Requirements: This Savings Offer may be redeemed only by patients or patient guardians who are 18 years of age or older and who are residents of the United States and its territories. Patients must have commercial insurance or be uninsured. This program is not valid for prescriptions that are reimbursed, in whole or in part, by any state or federally funded healthcare program, including but not limited to any state pharmaceutical assistance program, Medicare (Part D or otherwise), Medicaid, Medigap, VA or DOD, or TRICARE (regardless of whether Gwyn Lo is covered by such government program); not valid if the patient is Medicare eligible and enrolled in an employer-sponsored health plan or prescription benefit program for retirees; and not valid if the patient’s insurance plan is paying the entire cost of this prescription. This program is void outside the US and its territories or where prohibited by law, taxed, or restricted. This program may not be available in all states. 

Patients who are enrolled in Medicare, Medicaid, or another state or federal healthcare program may only use this Savings Offer program if paying with cash for the prescription covered by this program outside of their government insurance benefit, and no claim is submitted to Medicare, Medicaid, or any federal or state healthcare program. Such cash-pay patients must not apply any out-of-pocket costs incurred using this program toward any government insurance benefit out-of-pocket spending calculations, such as Medicare Part D true out-of-pocket (TrOOP) costs. Once enrolled in this program, Medicare Part D patients must continue to purchase the prescription through this program (and not under the patient’s prescription drug benefit) for the remainder of the calendar year.

This Savings Offer is not health insurance. This Savings Offer is not transferable, and the amount of the savings cannot exceed the patient’s out-of-pocket costs. This Savings Offer cannot be combined with any other rebate/coupon, cash discount card, free trial, or other offer for the specified prescription. This Savings Offer is not redeemable for cash.

NOTICE: Data related to your use of this Savings Offer may be collected, analyzed, and shared with Viatris Specialty LLC for market research and other purposes related to assessing its programs. Data shared with Viatris Specialty LLC will be aggregated and de-identified, meaning it will be combined with data related to other savings card redemptions and will not identify you.

Patient Instructions: By using this Savings Offer, you hereby accept and agree to abide by these terms and conditions. Further, you acknowledge and agree that you currently meet the eligibility criteria and other requirements described herein every time you use this Savings Offer and that you understand and will comply with the following additional terms and conditions:

• You have not submitted and will not submit a claim for reimbursement under any federal, state, or other government-funded programs for this prescription, and you will not apply any out-of-pocket costs incurred using this Savings Offer toward any government insurance benefit out-of-pocket cost obligations, such as Medicare Part D TrOOP costs.
• Your use of this Savings Offer must be consistent with the terms of any drug benefit provided by your commercial health insurer, health plan, or private third-party payer. You agree to report the use of this Savings Offer to your commercial insurer if required.
• Where required, a Savings Offer and prescription drug insurance card, along with a valid prescription for Gwyn Lo, must be presented to your pharmacist.
• Should you begin receiving prescription benefits from any government-funded program, you will withdraw from this Savings Offer program.

Pharmacist Instructions: When you accept this Savings Offer, you are certifying that you have received this Savings Offer from an eligible patient; you have received a valid prescription for Gwyn Lo for an eligible patient; you have dispensed the product as indicated; you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government programs for this prescription; and you will otherwise comply with these terms and all applicable terms and conditions. You further certify that your participation in this program is consistent with all applicable state laws and any obligations, contractual or otherwise, that you have as a pharmacy provider, and that you will report the use of this Savings Offer to the patient’s insurer if required.

• For Patients with an Eligible Third-Party Payer: Submit this claim to the patient’s commercial third-party payer first; then submit the balance due using BIN#: 637765 and PCN: CRX as a secondary payer COB with a “patient responsibility amount” using a valid Other Coverage Code (e.g., 8). The patient’s out-of-pocket cost will be reduced up to the maximum reimbursement limit for this Savings Offer program. Other cash discount cards are not valid as primary insurance under this Savings Offer.
• For Patients with an Eligible Third-Party Payer Without Product Coverage and for Patients Paying Cash: Please submit this claim with a valid Other Coverage Code (e.g., 1 or 3) to BIN#: 637765 and PCN: CRX. 
• For help processing this offer, call 1-224-536-6282.

For questions about this Gwyn Lo Saving Offer program, please call 1-224-536-6282, visit Gwynlo.com, or write to: Viatris Specialty LLC, 1000 Mylan Boulevard, Canonsburg, PA 15317.