SUFLAVE™ MEDICARE PART D ALTERNATIVE COUPON PROGRAM

Please complete all fields and confirm your agreement with the statements below to activate your card.

Patient First Name

Patient Last Name

Patient Date of Birth

Patient State

Medicare Part D Plan Name

Coupon Member ID (As shown on the card image on the letter)

I attest that I have a valid prescription for SUFLAVE and prescription drug insurance through a Medicare Part D or a Medicare Advantage prescription drug plan.

I agree to not seek reimbursement from my Medicare Part D or Medicare Advantage prescription plan for my out-of-pocket costs for SUFLAVE purchased with the coupon card.

I agree to not count my cost of SUFLAVE toward my Medicare Part D or Medicare Advantage prescription plan deductible or true out-of-pocket cost.

I agree to send the form letter provided with the coupon as notification to my Medicare Part D or Medicare Advantage prescription plan that SUFLAVE has been purchased outside of the plan benefit.

I agree to purchase my prescription for SUFLAVE before 12/31/2024 with this specific copay card and to not use Medicare Part D benefit for SUFLAVE.

Data related to your redemption of the SUFLAVE Medicare Part D Alternative Coupon Program card may be collected, analyzed, and shared with Braintree Laboratories, Inc. or any of its affiliates for market research and other purposes related to assessing patient savings programs. Data shared will be aggregated and de-identified, meaning it will be combined with data related to other card redemptions and will not identify the patient.

SUFLAVE™ MEDICARE PART D ALTERNATIVE COUPON PROGRAM

PATIENT ATTESTATION