PEXEVA®

Save up to $25 on every PEXEVA prescription

Dear Patient:
The PEXEVA® Co-Pay Benefit Card will pay for prescription drug plan co-pay amounts above $25 up to a maximum savings of $25 for each PEXEVA® prescription. To participate in the program, you must have a health plan prescription benefit and a PEXEVA® co-pay of greater than $25.

For example:	Example 1	Example 2
Your prescrition drug plan co-pay for PEXEVA^®	$35	$50
PEXEVA^® Co-Pay Benefit Card Savings	$10	$25
You Pay	$25	$25

*Maximum co-pay savings per prescription is $25.

How to save with your PEXEVA Co-Pay Benefit Card

• Present your PEXEVA® Co-Pay Benefit Card as well as your prescription drug plan benefit card when paying for your PEXEVA® prescription. It’s that easy to save up to $25 per prescription.

• To save up to $25 on every PEXEVA® prescription, be sure to keep the PEXEVA® Co-Pay Benefit Card and bring it to the pharmacy each time you fill a PEXEVA® prescription

Ask your pharmacy about their participation in the PEXEVA® Co-Pay Benefit Program. Physicians/Patients: For questions or additional information about the PEXEVA® Co-Pay Benefit Program, please call 1-800-773-0116, Mon-Fri 8:30 am to 5:00 pm EST.

See eligibility criteria below to see if you qualify. Just fill out your information below. Then click the "submit" button and you will receive a printable rebate page in a separate pop-up window.

Note: Lines with an asterisk (*) must be filled in.

First Name*:

Last Name*:

Street Address*:

Apt. Number:

City*:

State*:

Zip*:

Phone:

Email Address*:

Birthdate:

Gender:

Male

Female

Do you have a prescription for Pexeva? Yes No

If Yes, how long have you been taking Pexeva?

Have you ever taken Pexeva in the past? YesNo

Eligibility Criteria:

1.	This offer is not valid for prescriptions reimbursed in whole or in part by Medicaid, Medicare, federal or state programs (including any state prescription drug programs).
2.	The card is good for use only with PEXEVA® prescriptions at the time the prescription is filled by the pharmacist and dispensed to the patient. Patient must present a valid health plan prescription benefit card along with this card at time of purchase.
3.	Offer is not valid on prescriptions dispensed prior to the date of the first use of this card.
4.	Offer good only in the USA at participating retail pharmacies and cannot be redeemed at government-subsidized clinics.
5.	This offer is not valid for residents of Massachusetts whose prescriptions are covered in whole or in part by third party insurance, or where otherwise prohibited by law.
6.	This offer is good for up to a maximum of $25 in savings on any one Pexeva prescription.
7.	Please allow 10 to 14 business days for delivery.
8.	Noven has the right to cancel this offer, or change it, without notice.

If you have questions about the Pexeva Co-Pay Benefit Program, please call 800-773-0116.

Please read the information below before you submit your request.
Concerning Confidentiality: Noven respects your right to have personal and medical information kept confidential. When you click the "Submit" button below, you indicate to us that you want us to use the information you have provided for the purpose of administering the rebate [and sending you an introductory mailing about Pexeva]. Noven, and companies working with Noven, will not share your personal and medical information with any third parties (such as outside mailing lists).

	Check here if you also agree that Noven and companies working with Noven may use your information to help develop new Noven products, services and programs, provide you in the future with materials you may find useful, and contact you about health-related topics.
	Check here if you also agree that Noven may contact you from time to time about special offers and updates on Pexeva and related health issues.

Important Safety Information

Suicidal thoughts or behavior and antidepressant drugs
Short-term studies have shown that antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults. When deciding to use PEXEVA® or any other antidepressant in these age groups, people must balance the risk with the potential benefit to the patient. Short-term studies did not show an increased risk of suicidality with antidepressants compared to placebo in adults beyond age 24; the risk decreased in adults aged 65 and older. Depression and certain other psychiatric disorders are themselves associated with increases in the risk of suicide. Patients of all ages who are started on antidepressant therapy should be monitored by their doctor and watched closely to see if their condition worsens, if they have suicidal thoughts or behavior or if they exhibit any unusual changes in behavior. Families and caregivers need to understand that they should watch the patient closely and tell the doctor if they have any concerns. PEXEVA® is not approved for use in pediatric patients.

The most common side effects that have been reported with PEXEVA® include nausea, dry mouth, constipation, decreased appetite, infection, drowsiness, tremor, sweating, muscle weakness, trouble sleeping, abnormal ejaculation, impotence and other male genital disorders, and female genital disorders.

Please see Important Safety Information, including Black Boxed Warning. Please see accompanying full Prescribing Information including use in Pregnancy. (See WARNINGS-Clinical Worsening and Suicide Risk and Usage in Pregnancy: Teratogenic and Nonteratogenic Effects).

You are encouraged to report negative side effects of prescription drugs to the FDA.
Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.


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