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FOR US AUDIENCES ONLY

ExEm® Foam is committed
to patient access

PATIENT COPAY ASSISTANCE PROGRAM

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New Patient
Eligibility

Please answer the questions below by clicking “yes” or “no.” This will determine if you qualify for the program.

Web Card
1. Has your OBGYN/Fertility Specialist prescribed ExEm® Foam for you?
2. Are you 18 years of age or older?
3. Are you a resident of the United States, Puerto Rico, or any of the US territories?
4. Does the federal or state government pay anything for your prescription, either all of it or part of it? Examples of government programs that pay for medication are Medicaid, VA, DOD, or TRICARE.

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