NeedyMeds

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1 NeedyMeds Find help with the cst f medicine Thank yu fr dwnlading this patient assistance dcument frm NeedyMeds. We hpe this prgram will help yu get the medicine yu need. REMEMBER - Send yur cmpleted applicatin t address n the frm, NOT t NeedyMeds. Did yu knw that NeedyMeds has thusands f ther free resurces? Here s a lk at mre ways we can help yu save mney n medicine and healthcare csts. Each ne can be fund under the Patient Savings tab n ur website: Diagnsis-Based Assistance NeedyMeds lists thusands f assistance prgrams fr almst any health cnditin. If yu are ging thrugh chem treatment fr cancer, there are prgrams that can help with wig csts and scalp-cling prducts. We als list resurces fr free diabetes testing supplies, caregiver ldging supprt, and much mre. Free, Lw Cst, and Sliding Scale Clinics This ppular cllectin cntains infrmatin n 16,000+ free, lw cst, and sliding scale medical and dental clinics acrss the U.S. It s a great resurce if yu need affrdable medical treatment and dn t knw where t g. Cupns, Rebates & Mre Yu can use the NeedyMeds website t find nearly 2,000 cst-saving pprtunities fr bth prescriptin and ver-the-cunter drugs and medical supplies. Medical Transprtatin Need help getting t the dctr s ffice r medical facility? Yu may be eligible fr financial assistance if yu meet certain requirements. Finally, I want t tell yu abut the NeedyMeds Drug Discunt Card. Thusands f peple use this free, annymus, and easy-t-use tl t get the best price n their medicatins. T date, ur drug discunt card has saved patients ver $244,000,000. Check ut the next page t learn mre. Feel free t call ur tll-free helpline if yu have any questins. Yu can reach us at Mnday-Friday, 9am-5pm Eastern Time. Thanks fr using NeedyMeds! Please let us knw if we can d anything else t help yu affrd the csts f yur healthcare. Rich Sagall, MD Richard J. Sagall, MD President, NeedyMeds NeedyMeds.rg P.O. Bx 219 Glucester, MA Phne: inf@needymeds.rg

2 Clip the card and save NeedyMeds NeedyMeds.rg DRUG DISCOUNT CARD BIN: RX PCN: NMEDS RX GRP: PDFPDF ID: NMNA This is a drug discunt prgram, nt an insurance plan. NeedyMeds Drug Discunt Card Patient: Simply present this card t a participating pharmacy t receive a discunt n yur prescriptin. Patients wh have Medicare, including Part D, Medicaid r any state r federal prescriptin insurance can nly use this card if they chse nt t use their gvernment-spnsred drug plan fr their purchase. The card is nt valid in cmbinatin with thse prgrams. Fr questins cncerning the card, call r visit Pharmacist: Card must be presented t receive prgram benefits. Clear system f prir cardhlder infrmatin assciated with this universal cardhlder ID. Fr prcessing questins, call Argus Health Systems at Save up t 80% Use at ver 65,000 pharmacies natinwide including all majr chains Share the card with friends and family Use the card as ften as needed Free, n fees r registratin Never expires What if I have insurance? Anyne can use the card, but it can t be cmbined with insurance. Yu can use the card instead f insurance if: A drug isn t cvered by yur insurance Yur insurance has n drug cverage Yu have a high drug deductible Yu have met a lw medicine cap The card ffers a better price than yur cpay Yu are in the Medicare Part D dnut hle What drugs are cvered? The card is gd fr prescriptin drugs, ver-the-cunter medicines and medical supplies if written n a prescriptin blank, and pet prescriptin medicines purchased at a pharmacy. Yu ll save n mst, but nt all, prescriptins. T btain a plastic drug discunt card, send a self-addressed stamped envelpe t: NeedyMeds-PAP PO Bx 219 Glucester, MA The card is nt valid in cmbinatin with ther insurance plans, including Medicare, Medicaid r any state r federal prescriptin insurance. The card can be used nly if yu decide nt t use yur gvernment-spnsred drug plan fr yur purchases.

3 Patient Assistance Applicatin fr HUMIRA (adalimumab) The AbbVie Patient Assistance Prgram prvides AbbVie medicines at n cst t eligible patients experiencing financial difficulties. We review all applicatins n a case-by-case basis t supprt the AbbVie Patient Assistance Prgram s purpse f prviding prducts at n cst t individuals in need. Participatin in ur prgram is free; we d nt cllect any fees frm peple seeking ur assistance. CHECKLIST FOR SUBMITTING AN APPLICATION IF YOU ARE THE PRESCRIBER, COMPLETE PAGE 2 SECTION 1: Prescriber Infrmatin SECTION 2: Patient Histry, Diagnsis and Shipping Preference SECTION 3: Prescriptin SECTION 4: Prescriber Certificatin and Signature IF YOU ARE A PATIENT, COMPLETE PAGE 3. PLEASE READ PAGE 4 SECTION 5: Patient Infrmatin SECTION 6: Financial and Medical Infrmatin Als include prf f incme fr all in husehld. A cpy f yur current federal tax return is preferred. SECTION 7: Insurance Infrmatin If yu have Insurance, include frnt and back cpies f all prescriptin insurance card(s). SECTION 8: Patient Cnsent and Signature Carefully read the privacy ntice and terms f participatin in Sectin 10 n Page 4. Prvide yur cnsent fr eligibility determinatin by checking the bx in Sectin 8 Cnfirm yur understanding f ur privacy plicy by prviding yur signature and date in Sectin 8. SECTION 9: Additinal Permissin fr Prgram Purpses (Optinal) SECTION 10: Patient Privacy Ntice and Terms f Participatin Please keep a cpy fr yur recrds. FAX OR MAIL THE COMPLETED APPLICATION AND DOCUMENTATION TO THE FOLLOWING AbbVie Patient Assistance Prgram D , AP5 NE 1 N. Waukegan Rd. Nrth Chicag, IL Phne: Fax: Upn review f a cmpleted applicatin, we will ntify the prescriber and patient abut eligibility. If apprved, we will ship the medicatin t the patient s hme unless therwise indicated n the applicatin. Prir t each subsequent shipment, we will call the patient r prescriber t schedule the next delivery. Please cntact us at Mnday thrugh Friday fr additinal assistance AbbVie Patient Assistance Prgram H-APP1-18E-1 May 2018 Printed in U.S.A.

4 PRESCRIBER PRESCRIPTION AND CERTIFICATION TO BE COMPLETED AND FAXED BY PRESCRIBER PATIENT ASSISTANCE APPLICATION HUMIRA (adalimumab) D , AP5 NE; 1 N. WAUKEGAN RD NORTH CHICAGO, IL PHONE: FAX: PRESCRIBER INFORMATION Prescriber Name: MD DO Other: Rheum Derm Gastr Other: Office Name: Office Cntact Name: Address: City/State/Zip: NPI r SLN: Phne: Fax: Cllabrating/Supervising MD Name and NPI Name: NPI: 2 PATIENT HISTORY DIAGNOSIS SHIPPING PREFERENCE Patient s Name: DOB: Patient Weight* (if under age 18): N knwn allergies Allergies (Please list): N ther medicatins Other Medicatins (Please list): RHEUMATOID ARTHRITIS PSORIATIC ARTHRITIS PLAQUE PSORIASIS ANKYLOSING SPONDYLITIS CROHN S DISEASE ULCERATIVE COLITIS HIDRADENITIS SUPPURATIVA UVEITIS PEDIATRIC CROHN S DISEASE* POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS [JIA]* OTHER: Is yur patient NEW t Humira therapy? Yes N Check ONLY if yu prefer shipping t the Prescriber s ffice: 3 RX: MUST BE COMPLETED BY A LICENSED PRESCRIBER AND FAXED DIRECTLY FROM PRESCRIBER S OFFICE HUMIRA STARTING THERAPY Directins Qty CROHN S /ULCERATIVE COLITIS/HIDRADENITIS SUPPURATIVA STARTER PACKAGE (cntains 6 Humira 40 mg/0.8 ml PENS) Humira 40 mg/0.8 ml prefilled SYRINGE PSORIASIS/UVEITIS STARTER PACKAGE (cntains 4 Humira 40mg/0.8 ml PENS) Humira 40 mg/0.8 ml prefilled SYRINGE PEDIATRIC CROHN S DISEASE STARTER PACKAGE (cntains 3 Humira 40 mg/0.8 ml prefilled SYRINGES) Weight: > 40kg (88lbs) Fur 40 mg sc injectins day 1, tw 40 mg sc injectins day 15 Tw 40 mg sc injectins day 1, 2 and 15 Tw 40 mg sc injectins day 1, ne 40 mg sc injectin day 8 and 22 Weight: 17kg (37lbs) t < 40kg (88lbs) Tw 40 mg sc injectins day 1, ne 40 mg sc injectin day 15 # 6 # 4 # 3 N refills N refills N refills HUMIRA ONGOING THERAPY (Chse 1 frm each clumn) Humira 40 mg/0.8 ml AUTO INJECTOR PEN 40 mg sc injectin EVERY OTHER week Humira 40 mg/0.8 ml prefilled SYRINGE 40 mg sc injectin EVERY week Humira 20 mg/0.4 ml prefilled SYRINGE 20 mg sc injectin EVERY OTHER week Other: Other: Quantity (Chse ne) 3 mnths standard prgram supply Other: Refills (Chse ne) 1 year Other: PLEASE SUBMIT PRESCRIPTIONS ACCORDING TO YOUR SPECIFIC STATE LAWS, RULES AND REGULATIONS 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 X DATE: AND DATE: Substitutin Permitted Dispense as Written I verify that the infrmatin prvided is current, cmplete and accurate t the best f my knwledge. The Patient Assistance Prgram ( PAP ) reserves the right t request additinal infrmatin if needed and t change r discntinue the PAP at any time, withut ntice. I shall nt seek reimbursement fr any medicatin dispensed hereunder frm any gvernment prgram r third party, including patient, nr will I sell, trade r distribute any such medicatin. I als understand that the applicant s acceptance int the PAP shuld nt influence treatment decisins. By signing this frm, I authrize the PAP and its representatives t transmit this prescriptin frm electrnically, by facsimile, r by mail t a pharmacy designated by the PAP fr the dispensing f the medicatin called fr herein. I understand that I may nt delegate signature authrity. I certify that treatment with this medicatin is medically necessary. Fr full Prescribing Infrmatin please visit AbbVie Patient Assistance Prgram H-APP1-18E-1 May 2018 Page 2 f 4

5 PATIENT INFORMATION TO BE COMPLETED BY PATIENT PATIENT ASSISTANCE APPLICATION HUMIRA (adalimumab) D , AP5 NE; 1 N. WAUKEGAN RD NORTH CHICAGO, IL PHONE: FAX: PATIENT INFORMATION Patient Name: DOB: Sex: M F SSN (last fur digits ONLY): ǀ ǀ ǀ If yu d nt have an SSN, check here: Mailing Address: City/State/Zip: Shipping Address (N P.O. Bx): Preferred Phne: 6 FINANCIAL AND MEDICAL INFORMATION Mnthly Ttal Incme fr everyne in the husehld: $ Number f peple in yur husehld (including yurself): City/State/Zip: Cellphne Wrk Hme Alternate Phne: Cellphne Wrk Hme Please include financial dcumentatin fr everyne in the husehld. A cpy f yur current federal tax return is preferred. Number in husehld ver 18 yrs ld with incme: Treating Physician Name: Treating Physician Phne: Fax: **If yu have any changes t yur medical infrmatin please call us at ** 7 INSURANCE INFORMATION I have n insurance cverage g t Sectin 8 If yu have insurance please prvide insurance details belw and attach a frnt and back cpy f the insurance card. Include detailed list f medical expenses fr husehld, including medicatins, ffice visit cpays, insurance premiums, medical bills, etc. 8 PRIMARY INSURANCE Insurance Cmpany: Insurance C. Phne: SECONDARY INSURANCE Insurance Cmpany: Insurance C. Phne: Plicy #: Grup #: Plicy #: Grup #: Plicyhlder Name: DOB: Plicyhlder Name: DOB: Relatinship t Plicyhlder: MEDICARE INFORMATION: Relatinship t Plicyhlder: Are yu enrlled in a Medicare Prescriptin Drug Plan (Medicare Part D)? Yes N Unsure If Yes, please prvide yur Medicare Part A Identificatin #: Value f yur assets: $ Assets include checking and savings accunts, CD s, stcks and bnds, savings bnds, mutual funds, IRAs and ther investments, cash at hme r anywhere else, and the value f yur life insurance plicies if turned in fr cash right nw. D nt include yur hme, vehicles, burial plts, r persnal pssessins. 8 PATIENT CONSENT PLEASE REVIEW PRIVACY NOTICE AND PROGRAM TERMS ON PAGE 4 TO UNDERSTAND HOW WE USE YOUR PERSONAL DATA I acknwledge that I have prvided accurate and cmplete infrmatin and understand the Patient Terms f Participatin n Page 4. CHECK THE BOX: PLEASE SIGN AND DATE: I understand that I am prviding written instructins t the Prgram under the Fair Credit Reprting Act authrizing the Prgram t btain infrmatin abut my credit prfile frm credit reprting agencies r ther surces. I authrize the Prgram t btain such infrmatin slely t determine PAP eligibility. My signature belw certifies that I have read, understd and agreed t the HIPAA Authrizatin n Page 4. x PATIENT SIGNATURE / LEGAL REPRESENTATIVE (indicate relatinship) DATE 9 ADDITIONAL PERMISSION FOR PURPOSES OF THE PROGRAM (ptinal) I permit the AbbVie Patient Assistance Prgram t speak with the fllwing persn abut this applicatin: Name: Relatinship: Phne Number: Patient Signature: Date: Fr full Prescribing Infrmatin please visit AbbVie Patient Assistance Prgram H-APP1-18E-1 May 2018 Page 3 f 4

6 PATIENT TERMS OF PARTICIPATION AND PRIVACY NOTICE PATIENT: PLEASE READ AND SIGN IN SECTION 8 PATIENT ASSISTANCE APPLICATION HUMIRA (adalimumab) D , AP5 NE; 1 N. WAUKEGAN RD NORTH CHICAGO, IL PHONE: FAX: PATIENT PRIVACY NOTICE AND TERMS OF PARTICIPATION HIPAA AUTHORIZATION Please prvide signature in Sectin 8 n Page 3 f Enrllment Frm I authrize my healthcare prviders, pharmacies, insurers, and labratry testing facilities (my Healthcare Cmpanies ) t disclse infrmatin abut me, my medical cnditin, treatment, insurance cverage, and payment infrmatin in relatin t my use f AbbVie prducts, t the AbbVie Patient Assistance Prgram, AbbVie, its affiliates, and agents/cntractrs (cllectively the Prgram ), t enrll me in and prvide me with PAP Services. I understand that infrmatin released under this Authrizatin will n lnger be prtected by HIPAA. I als understand that if my Healthcare Cmpanies use r disclse my Persnal Infrmatin fr marketing purpses, they may receive financial remuneratin. I understand that I am nt required t sign this Authrizatin and that my Healthcare Cmpanies will nt cnditin my treatment, payment, enrllment, r eligibility fr benefits n whether I sign this Authrizatin. Hwever, I understand that if I d nt sign this Authrizatin, I cannt take part in the AbbVie Patient Assistance Prgram ( PAP ) (shuld I qualify). This Authrizatin will expire in 10 years r a shrter perid if required by state law, unless I cancel it sner by calling r by writing t the AbbVie Patient Assistance Prgram, D , AP5 NE; 1 N. Waukegan Rd, Nrth Chicag, IL I understand that cancelling my Authrizatin will nt affect any use f my infrmatin that ccurred befre my request was prcessed. PATIENT TERMS OF PARTICIPATION The Prgram prvides AbbVie medicines at n cst t eligible patients experiencing financial difficulties. Participatin in ur prgram is free; we d nt cllect any fees frm peple seeking ur assistance. Medicatin assistance is dependent n yur ability t meet the eligibility criteria fr PAP as determined by the Prgram. The Prgram des nt have any bligatin t prvide the PAP services t yu and is nt liable in the prvisin f these services. The PAP may be changed r discntinued withut ntice. Yu will nt seek reimbursement fr any prducts dispensed under the PAP. Yu will ntify the PAP if yur insurance r financial situatin changes. If this applicatin has been cmpleted by a persnal representative, the persnal representative will prvide a cpy f this cmpleted applicatin t yu. If yu are a member f a Medicare Prescriptin Drug Plan and are qualified fr PAP assistance, yu will: (i) be eligible t btain the medicatin frm the PAP fr a calendar year term (ii) nt purchase this medicatin under yur Medicare Prescriptin Drug Plan while enrlled in the PAP; (iii) nt submit claims nr seek true ut-f-pcket (TrOOP) credit fr the medicatin prvided during yur enrllment; (iv) prvide written ntificatin t yur Medicare Prescriptin Drug Plan that yu are receiving yur medicatin at n cst utside f the Medicare Part D benefit. In rder fr yu t participate, the PAP will use and disclse yur persnal infrmatin, including yur health infrmatin, cllected n this enrllment frm and thrugh participatin in the PAP fr the fllwing purpses: (1) T determine yur eligibility fr the PAP and t prvide yu with related services, including: transfer t a separate private r public payer prgram, reimbursement services, services t ship yur medicatin, and ther supprt services ( PAP Services ). (2) T btain infrmatin frm yur credit prfile abut yur incme fr the sle purpse f determining eligibility fr the PAP. This ntice serves as written instructin under the Fair Credit Reprting Act authrizing the PAP t btain this infrmatin. (3) T perfrm research and data analytics t develp and evaluate prducts, services, materials, and treatments. (4) T administer and maintain the high quality f the PAP, including but nt limited t case review, cmpliance checks, audit review and accunting purpses. PAP may cmbine the infrmatin it receives abut yu with infrmatin frm ther surces. Hwever, PAP will nt sell r rent any infrmatin that can identify yu t third parties fr their wn purpses r therwise use r disclse any infrmatin that can identify yu fr any purpse nt authrized abve. If yu have questins abut this Privacy Ntice, want t update yur infrmatin, r terminate yur PAP enrllment, please call r write t us at D , AP5 NE; 1 N. Waukegan Rd, Nrth Chicag, IL Fr full Prescribing Infrmatin please visit AbbVie Patient Assistance Prgram H-APP1-18E-1 May 2018 Page 4 f 4