NeedyMeds

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1 NeedyMeds Find help with the cost of medicine Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need. REMEMBER - Send your completed application to address on the form, NOT to NeedyMeds. Did you know that NeedyMeds has thousands of other free resources? Here s a look at more ways we can help you save money on medicine and healthcare costs. Each one can be found under the Patient Savings tab on our website: Diagnosis-Based Assistance NeedyMeds lists thousands of assistance programs for almost any health condition. If you are going through chemo treatment for cancer, there are programs that can help with wig costs and scalp-cooling products. We also list resources for free diabetes testing supplies, caregiver lodging support, and much more. Free, Low Cost, and Sliding Scale Clinics This popular collection contains information on 16,000+ free, low cost, and sliding scale medical and dental clinics across the U.S. It s a great resource if you need affordable medical treatment and don t know where to go. Coupons, Rebates & More You can use the NeedyMeds website to find nearly 2,000 cost-saving opportunities for both prescription and over-the-counter drugs and medical supplies. Medical Transportation Need help getting to the doctor s office or medical facility? You may be eligible for financial assistance if you meet certain requirements. Finally, I want to tell you about the NeedyMeds Drug Discount Card. Thousands of people use this free, anonymous, and easy-to-use tool to get the best price on their medications. To date, our drug discount card has saved patients over $244,000,000. Check out the next page to learn more. Feel free to call our toll-free helpline if you have any questions. You can reach us at Monday-Friday, 9am-5pm Eastern Time. Thanks for using NeedyMeds! Please let us know if we can do anything else to help you afford the costs of your healthcare. Rich Sagall, MD Richard J. Sagall, MD President, NeedyMeds NeedyMeds.org P.O. Box 219 Gloucester, MA Phone: info@needymeds.org

2 Clip the card and save NeedyMeds NeedyMeds.org DRUG DISCOUNT CARD BIN: RX PCN: NMEDS RX GRP: PDFPDF ID: NMNA This is a drug discount program, not an insurance plan. NeedyMeds Drug Discount Card Patient: Simply present this card to a participating pharmacy to receive a discount on your prescription. Patients who have Medicare, including Part D, Medicaid or any state or federal prescription insurance can only use this card if they choose not to use their government-sponsored drug plan for their purchase. The card is not valid in combination with those programs. For questions concerning the card, call or visit Pharmacist: Card must be presented to receive program benefits. Clear system of prior cardholder information associated with this universal cardholder ID. For processing questions, call Argus Health Systems at Save up to 80% Use at over 65,000 pharmacies nationwide including all major chains Share the card with friends and family Use the card as often as needed Free, no fees or registration Never expires What if I have insurance? Anyone can use the card, but it can t be combined with insurance. You can use the card instead of insurance if: A drug isn t covered by your insurance Your insurance has no drug coverage You have a high drug deductible You have met a low medicine cap The card offers a better price than your copay You are in the Medicare Part D donut hole What drugs are covered? The card is good for prescription drugs, over-the-counter medicines and medical supplies if written on a prescription blank, and pet prescription medicines purchased at a pharmacy. You ll save on most, but not all, prescriptions. To obtain a plastic drug discount card, send a self-addressed stamped envelope to: NeedyMeds-PAP PO Box 219 Gloucester, MA The card is not valid in combination with other insurance plans, including Medicare, Medicaid or any state or federal prescription insurance. The card can be used only if you decide not to use your government-sponsored drug plan for your purchases.

3 Patient Assistance Application for Kaletra (lopinavir/ritonavir) and Norvir (ritonavir) The AbbVie Patient Assistance Foundation provides AbbVie medicines at no cost to eligible patients experiencing financial difficulties. We review all applications on a case-by-case basis to support the AbbVie Patient Assistance Foundation s purpose of providing products at no cost to individuals in need. Participation in our program is free; we do not collect any fees from people seeking our assistance. CHECKLIST FOR SUBMITTING AN APPLICATION IF YOU ARE THE PRESCRIBER, COMPLETE PAGE 2 o SECTION 1: Prescriber Information o SECTION 2: Patient Information o SECTION 3: Medication Request o SECTION 4: Prescriber Certification and Signature IF YOU ARE A PATIENT, COMPLETE PAGE 3. PLEASE READ PAGE 4 o SECTION 5: Patient Information o SECTION 6: Financial Information o SECTION 7: Insurance Information If you have Insurance, include front and back copies of all prescription insurance card(s). o SECTION 8: Patient Consent and Signature Carefully read the privacy notice and terms of participation in Section 10 on Page 4. Confirm your understanding of our privacy policy by providing your signature and date in Section 8. o SECTION 9: Additional Permission for Program Purposes (Optional) o SECTION 10: Patient Privacy Notice and Terms of Participation Please keep a copy for your records. FAX OR MAIL THE COMPLETED APPLICATION AND DOCUMENATION TO THE FOLLOWING AbbVie Patient Assistance Foundation PO Box 270 Phone: Fax: Upon review of a completed application, we will notify the prescriber and patient about eligibility. If approved, we will ship the medication to the prescriber s office. Patient or prescriber please call to request refill. Please contact us at Monday through Friday for additional assistance AbbVie Patient Assistance Foundation V-APP1-18D-3 April 2018 Printed in U.S.A.

4 PRESCRIBER PRESCRIPTION AND CERTIFICATION TO BE COMPLETED BY PRESCRIBER PATIENT ASSISTANCE APPLICATION Kaletra (lopinavir/ritonavir) and Norvir (ritonavir) AbbVie Patient Assistance Foundation PO Box 270 PHONE: FAX: PRESCRIBER INFORMATION Prescriber Name: MD DO Other: Office Name: Address: Office Contact Name: City/State/Zip: NPI: Phone: Fax: Tax ID: DEA/SLN: DEA/SLN EXIPRATION DATE: 2 PATIENT INFORMATION Patient s Name: DOB: 3 MEDICATION REQUESTED: MUST BE COMPLETED BY A LICENSED PRESCRIBER PRODUCT: STRENGTH: DIRECTIONS REFILLS Reorders allowed up to 1 year Reorders allowed up to 1 year 4 PRESCRIBER PLEASE SIGN AND DATE PRESCIBER MUST MANUALLY SIGN BELOW 4 RUBBER STAMPS, SIGNATURE BY OTHER OFFICE PERSONNEL OR COMPUTER GENERATED IMAGES ARE NOT ALLOWED PRESCRIBER SIGNATURE: X DATE: I verify that the information provided is current, complete and accurate to the best of my knowledge. The Foundation reserves the right to request additional information if needed and to change or discontinue the PAP at any time, without notice. I shall not seek reimbursement for any medication dispensed hereunder from any government program or third party, including patient, nor will I sell, trade or distribute any such medication. I also understand that the applicant s acceptance into the PAP should not influence treatment decisions. I understand that I may not delegate signature authority. I certify that treatment with this medication is medically necessary AbbVie Patient Assistance Foundation V-APP1-18D-3 April 2018 Page 2 of 4

5 PATIENT PLEASE COMPLETE, SIGN AND DATE PATIENT ASSISTANCE APPLICATION Kaletra (lopinavir/ritonavir) and Norvir (ritonavir) PO BOX 270 PHONE: FAX: PATIENT INFORMATION Patient Name: DOB: Sex: M F SSN (last four digits ONLY): ǀ ǀ ǀ If you do not have an SSN, check here: Mailing Address: City/State/Zip: Shipping Address (No P.O. Box): Preferred Phone: Ok to leave a voic City/State/Zip: Alternate Phone: Ok to leave a voic 6 FINANCIAL INFORMATION Monthly Total Income for everyone in the household: $ Total number of people in your household (including yourself): Number in household over 18 years old with income: 7 INSURANCE INFORMATION I have no insurance coverage go to Section 8 If you have insurance please provide insurance details below and attach a front and back copy of the insurance card. Please include a detailed list of prescriptions such as a Pharmacy print-out and medical expenses for the household you would like us to consider. Medicare Medicare Part D Medicaid Private Insurance INSURANCE INFORMATION Group or Policy Number Insurance Name and Phone ADAP ADAP Waitlisted or Pending State Elderly Drug Assistance State Children Health Insurance Veterans Assistance MEDICARE INFORMATION: Are you enrolled in a Medicare Prescription Drug Plan (Medicare Part D)? Yes No If Yes, please provide your Medicare Part A Identification #: Value of your assets: $ Assets include checking and savings accounts, CD s, stocks and bonds, savings bonds, mutual funds, IRAs and other investments, cash at home or anywhere else, and the value of your life insurance policies if turned in for cash right now. Do not include your home, vehicles, burial plots, or personal possessions. 8 PATIENT CONSENT PLEASE REVIEW PRIVACY NOTICE AND PROGRAM TERMS ON PAGE 4 TO UNDERSTAND HOW WE USE YOUR PERSONAL DATA 8 PLEASE SIGN I acknowledge that I have provided accurate and complete information and understand the Patient Terms of Participation on Page 4. My signature below certifies that I have read, understood and agreed to the HIPAA Authorization on Page 4. x PATIENT SIGNATURE / LEGAL REPRESENTATIVE (indicate relationship) DATE 9 ADDITIONAL PERMISSION FOR PURPOSES OF THE PROGRAM (optional) I permit the AbbVie Patient Assistance Foundation to speak with the following person about this application: Name: Relationship: Phone Number: Patient Signature: Date: 2018 AbbVie Patient Assistance Foundation V-APP1-18D-3 April 2018 Page 3 of 4

6 PATIENT TERMS OF PARTICIPATION AND PRIVACY NOTICE PATIENT: PLEASE READ AND SIGN IN SECTION 8 PATIENT ASSISTANCE APPLICATION Kaletra (lopinavir/ritonavir) and Norvir (ritonavir) PO Box 270 PHONE: FAX: PATIENT PRIVACY NOTICE AND TERMS OF PARTICIPATION HIPAA AUTHORIZATION Please provide signature in Section 8 on Page 3 of Enrollment Form I authorize my healthcare providers, pharmacies, insurers, and laboratory testing facilities (my Healthcare Companies ) to disclose information about me, my medical condition, treatment, insurance coverage, and payment information in relation to my use of AbbVie products, to the AbbVie Patient Assistance Foundation, AbbVie, its affiliates, and agents/contractors (collectively the Foundation ), to enroll me in and provide me with PAP Services. I understand that information released under this Authorization will no longer be protected by HIPAA. I also understand that if my Healthcare Companies use or disclose my Personal Information for marketing purposes, they may receive financial remuneration. I understand that I am not required to sign this Authorization and that my Healthcare Companies will not condition my treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization. However, I understand that if I do not sign this Authorization, I cannot take part in the AbbVie Patient Assistance Program ( PAP ) (should I qualify). This Authorization will expire in 10 years or a shorter period if required by state law, unless I cancel it sooner by calling or by writing to the AbbVie Patient Assistance Foundation, PO BOX 270,. I understand that cancelling my Authorization will not affect any use of my information that occurred before my request was processed. PATIENT TERMS OF PARTICIPATION The Foundation provides AbbVie medicines at no cost to eligible patients experiencing financial difficulties. Participation in our program is free; we do not collect any fees from people seeking our assistance. Medication assistance is dependent on your ability to meet the eligibility criteria for PAP as determined by the Foundation. The Foundation does not have any obligation to provide the PAP services to you and is not liable in the provision of these services. The PAP may be changed or discontinued without notice. You will not seek reimbursement for any products dispensed under the PAP. You will notify the PAP if your insurance or financial situation changes. If this application has been completed by a personal representative, the personal representative will provide a copy of this completed application to you. If you are a member of a Medicare Prescription Drug Plan and are qualified for PAP assistance, you will: (i) be eligible to obtain the medication from the PAP for a calendar year term (ii) not purchase this medication under your Medicare Prescription Drug Plan while enrolled in the PAP; (iii) not submit claims nor seek true out-of-pocket (TrOOP) credit for the medication provided during your enrollment; (iv) provide written notification to your Medicare Prescription Drug Plan that you are receiving your medication at no cost outside of the Medicare Part D benefit. In order for you to participate, the PAP will use and disclose your personal information, including your health information, collected on this enrollment form and through participation in the PAP for the following purposes: (1) To determine your eligibility for the PAP and to provide you with related services, including: transfer to a separate private or public payer program, reimbursement services, services to ship your medication, and other support services ( PAP Services ). (2) To perform research and data analytics to develop and evaluate products, services, materials, and treatments. (3) To administer and maintain the high quality of the PAP, including but not limited to case review, compliance checks, audit review and accounting purposes. PAP may combine the information it receives about you with information from other sources. However, PAP will not sell or rent any information that can identify you to third parties for their own purposes or otherwise use or disclose any information that can identify you for any purpose not authorized above. If you have questions about this Privacy Notice, want to update your information, or terminate your PAP enrollment, please call or write to us at PO BOX 270, Somerville, NJ AbbVie Patient Assistance Foundation V-APP1-18D-3 April 2018 Printed in U.S.A. Page 4