SUFLAVE<sup>®</sup> MEDICARE PART D ALTERNATIVE COUPON PROGRAM

SUFLAVE^® MEDICARE PART D ALTERNATIVE SAVINGS PROGRAM

If your Medicare prescription drug insurance does not cover SUFLAVE^® or if your out-of-pocket costs exceed $60* for your Medicare Part D prescription of SUFLAVE^®, Azurity Pharmaceuticals, Inc. may be able to help.

With this program, you no longer seek reimbursement for your SUFLAVE^® prescription through your Medicare provider for out-of-pocket costs. Instead, you can use this Medicare Part D Alternative Savings Program. This program has no impact on your current insurance plan. Your Medicare Part D plan remains the same. To sign up for this savings program, just follow the 3 steps shown on the instructions that will be included with your card. If you have questions related to this program or need assistance activating the card, please call 800-208-8121.

*Terms, conditions, and limitations apply. Most eligible patients may pay as little as $60. Terms and Conditions below.

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

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All fields are required.

Patient First Name

Patient Last Name

Patient Date of Birth

Patient State

Medicare Part D Prescription Plan Name

Medicare Part D Prescription Plan Member ID Number

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 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 card 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 the end of the current calendar year with this specific card and to not use Medicare Part D benefit for SUFLAVE^®.

Data related to your redemption of the SUFLAVE^® Medicare Part D Alternative Savings Program card may be collected, analyzed, and shared with Azurity Pharmaceuticals, 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.

PATIENT TERMS AND CONDITIONS

SUFLAVE^® Medicare Part D Alternative Savings Program card is valid for a cost reduction of a qualifying prescription of SUFLAVE^® for eligible patients.
SUFLAVE^® Medicare Part D Alternative Savings Program card can only be used by eligible patients one time for SUFLAVE^®. Subsequent SUFLAVE^® prescriptions will require a new card.
You must have prescription drug insurance through a Medicare Part D or a Medicare Advantage prescription drug plan.
Patients participating in Medicare Part D or a Medicare Advantage prescription drug plan who are eligible to use the SUFLAVE^® Medicare Part D Alternative Savings Program card must agree to the program terms in order to use this card.
You must agree to not seek reimbursement from your Medicare or Medicare Advantage prescription plan for your out-of-pocket costs for SUFLAVE^® purchased with this card.
You must also agree to not count the cost of SUFLAVE^® toward your deductible or true out-of-pocket cost.
You must notify your prescription plan that you have purchased SUFLAVE^® outside of your plan benefit by sending the attached letter to the your Medicare Part D provider.
You must purchase your prescription for SUFLAVE^® before the end of the current calendar year with this card and not use your Medicare Part D benefit for SUFLAVE^®.
Program is not valid for any patients with commercial/private insurance, uninsured patients or patients with prescription coverage under any other federal or state health program such as Medicaid or TRICARE^®.
No other purchase necessary.
SUFLAVE^® Medicare Part D Savings Program card is not transferable. No substitutions are permitted. Cannot be combined with any other coupon, free trial, discount prescription savings card, or other offer not already associated with this offer.
SUFLAVE^® Medicare Part D Savings Program card is not insurance.
SUFLAVE^® Medicare Part D Savings Program card can be used at mail-order pharmacies.
SUFLAVE^® Medicare Part D Alternative Savings Program card can only be used by eligible United States residents at participating eligible retail pharmacies in the United States.
SUFLAVE^® Medicare Part D Alternative Savings Program card is the property of Azurity Pharmaceuticals, Inc. and must be turned in on request.
It is illegal to sell, purchase, trade, or counterfeit the SUFLAVE^® Medicare Part D Alternative Savings Program Card. Void if reproduced. Void where prohibited by law, taxed, or restricted.
Azurity Pharmaceuticals, Inc. reserves the right to rescind, revoke or amend this offer at any time without notice.
Data related to your redemption of the SUFLAVE^® Medicare Part D Alternative Savings Program card may be collected, analyzed, and shared with Azurity Pharmaceuticals, Inc. and 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 SAVINGS PROGRAM

PATIENT TERMS AND CONDITIONS

SUFLAVE^® MEDICARE PART D ALTERNATIVE SAVINGS PROGRAM