Intrarosa

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The INTRAROSA® Medicare Part D Coupon Program is sponsored by Millicent U. S. Inc. and designed to help reduce your out-of-pocket cost for INTRAROSA® if your Medicare Part D plan does not cover the product, or your out-of-pocket costs exceed $85* for a 28-day supply, and you opt out of using your Medicare Part D prescription benefit in conjunction with this offer.

Please note that you have the option to use existing prescription coverage if you have it. If you elect to take advantage of this offer, you will need to opt out of using your Medicare Part D prescription benefit and agree to certain conditions.

To receive your INTRAROSA® Medicare Part D coupon, please complete the requested information below.

*Terms, conditions and limitations apply. Most eligible patients may pay as little as $85. Please see below for the program’s full Eligibility Criteria, Terms and Conditions.

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Please enter patient date of birth.
Please enter patient zip code.
Please enter patient phone number.
Please enter patient email address.

You must agree to each of the following statements to be eligible for the Part D Coupon Program:

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