Covis Pharmaceuticals, Inc. Patient Assistance Program

Covis Pharmaceuticals, Inc. Patient Assistance Program Dear Applicant, Thank you for your interest in the Covis Pharmaceuticals, Inc. Patient Assistance Program. Enclosed you will find the application you requested. To participate in our program, it is important that you complete all requested information and sign where indicated. Incomplete applications will not be processed until missing information is received. Program Eligibility o Each patient must submit an application. o Patient must be a US citizen or resident with a Social Security Number. o Patient must be under the care of a licensed healthcare provider that is authorized to prescribe, dispense and administer medicine in the US. o Patient's prescription for Covis product must not be covered by any insurance program either private and/or public. o Patient must meet annual household income requirements. (See Checklist Under Income Eligibility Requirements) o If insured, patient must have spent a minimum of $250 out of pocket on prescription medications for the current calendar year. o All sections must be completed. Incomplete applications will not be processed until all information is present. Instructions for Patient o Indicate whether applying for Patient Assistance Program or coupon for medication. o Complete Patient Information, Patient Eligibility Information and Patient Insurance Information sections on application. o Sign application under Patient Signature section. If unable to sign a person with power of attorney may sign on patient's behalf. o Have prescribing doctor complete and sign the Prescriber Information Section. o Complete and sign the Authorization to Use or Disclose Health Information [HIPPA]. o If insured, attach photocopy of front and back of insurance card. If more than one insurance include photocopy of all insurance cards. o If insured through Medicare Part D, sign under Medicare Part D Enrollee Certification. o If insured, provide proof of Out of Pocket Expense. (see Out of Pocket Expenses) o Provide proof of ANNUAL household income. For documentation required see Household Income Documentation. Show for all residents with income. Out of Pocket Expenses o If insured privately or through Medicare/Medicaid, there is a minimum requirement of $250 needed to be paid out of pocket for the current calendar year. o Proof of out of pocket expense is required and may be submitted using a print out from a pharmacy. o Expense may account for any prescription medication taken by person applying for assistance. This does not include family or other household members. Household Income Requirements Total Household Income Must Not Exceed the Following: Household Income Documentation The following options for income documentation are acceptable (some options may require more than one form of income documentation): o Most recently filed 1040 Federal Tax Return and most recent W-2. o Most recently filed 1040 Federal Tax Return and 3 most recent Pay Stubs. o Most recently filed 1040 Federal Tax Return and Social Security Benefit Statement. o Most recently filed 1040 Federal Tax Return and SSA-1099. o IRS 4506-T Transcript submitted with Covis information under section 5 as well as a Zero Income Letter from physician on physician's letter head. o Copy of an Unemployment Determination Letter, Social Security Benefit Statement and Most recent Federal Tax Return. o Copy of an Unemployment Determination Letter, 401k, Social Security Benefit Statement, IRA-1 and Most recent Federal Tax Return. Prescriber Requirements: Must be completed by physician o Complete and sign the Prescriber Information section. o Check insurance under Reimbursement Services section. o Check whether or not you have patient's HIPAA consent on file. o In order to process the application include your NPI#. o Complete the Requested Medication section. Include: Drug Name, Strength, Quantity Requested for 90 Day Supply, Number of Refills and Signature. With Prescriber's Signature we will honor this as a legal prescription. Form Submission Options Email pap@covispharma.com If Approved & After Notification Of Acceptance: Number in Household Annual Income 1 $35,126 2 $47,347 3 $59,567 4 $71,788 5 $84,009 For Each Additional add $12,221 Fax 1-877-438-9759 Please do not fax multiple submissions of the application. o Truax Patient Services Pharmacy will be faxed Patient's legal prescription on behalf of the Prescribing Doctors Office. o Truax Patient Services Pharmacy will contact Patient or Contact Person to enroll Patient. o Truax Patient Services Pharmacy: 1-877-438-9759 Brian Truax www.truaxpatientservices.com U.S Mail Covis PAP 602 Beltrami Ave. NW #105 Bemidji, MN 56601 If you have any questions or need further assistance, please contact Truax Patient Services via: FAX: 1-877-438-9759 EMAIL: pap@covispharma.com PHONE: 1-877-438-9759 Sincerely, Brian Truax Truax Patient Services *Please note, program rules are subject to change without notice. Cover Letter Rev 05/22/2013

Covis Pharmaceuticals, Inc. Patient Assistance Program Application PATIENT INFORMATION *To be completed by the Patient First Name: MI: Last Name: Gender: Male Female Mailing Address: City: State: Zip Code: Social Security #: - - Date of Birth: / / Phone #: ( ) Email: @ ADVOCATE: CONTACT INFORMATION Name: Fax #: ( ) Phone #: ( ) Email: @ PATIENT ELIGIBILITY INFORMATION *Attach 2 Forms for Verification of Annual Household Income Annual Household Income: $ Medications Currently Taking: Total # of people in the household: 1 2 3 4 5 other Drug Allergies: Are you currently enrolled in a Medicare Part D Prescription Drug Plan? YES NO Do you currently have any public or private prescription drug coverage? YES NO Are you currently enrolled in any benefit program that helps you pay for Prescription Drugs? YES NO Have you spent $250 or more Out of Pocket this calendar year for your medications? YES NO Prescription Out Of Pocket Expense: $ PATIENT INSURANCE INFORMATION *Attach proof of out of pocket expense for this calendar year from your pharmacy *Attach Photocopy of Card(s) Front & Back Primary Insurance: Policy Holders Name: Policy #: Insurance Phone #: Secondary Insurance: Policy Holders Name: Group #: Policy #: Group #: ( ) Insurance Phone #: ( ) *Signature is required I attest that the above information is complete and accurate. I attest that I have insufficient financial resources to pay for the prescribed therapy. I acknowledge and agree not to submit an insurance claim or other claim for payment to any third-party payor (private or government) for the medication. By m signature, I authorize the release of the information about me and my medical condition to the Covis Pharmaceuticals, Inc. Patient Assistance Program (Covis PAP) and/or their agents. I authorize the Covis PAP and/or their agents to use and disclose such information for the assessment of my eligibility fo and enrollment into the Covis PAP and administration of the Covis PAP, which may include contacting my insurer, public funding programs, social workers, advocacy organizations, healthcare providers, or other persons or entities the Covis PAP may deem appropriate to release all medical records o requested information bearing on my eligibility to and benefits under the program. My signature certifies that the medication received from Covis PAP will not be resold nor offered for sale, trade or barter and will not be returned for credit. Additionally, I agree that at any time during my enrollment, the Covi PAP may request additional documentation to authenticate the statements made on my application. The Covis PAP and/or their agents agree not to disclose any information to any third party except as authorized by me or as required by law. I understand that application to the patient assistance program does not guarantee that assistance will be obtained. I understand that Covis PAP reserves the right to change or cancel the patient assistance program at any time. I agree that Covis PAP may contact me for additional information relating to this application either by fax or any other form of communication including but not limited to e-mail and telephone. Covis Pharmaceuticals, Inc. understands your information is private. Any information you provide will only be used by COVIS PAP and/or their agents and parties acting on their behalf to administer the Covis PAP program and related services, and to comply with applicable legal requirements. Patients Signature Relationship (if other than patient) Printed Name Date VERIFICATION OF NO INSURANCE *To be completed by the Prescribing Physician or Authorized Representative I verify Patient Name has no form of insurance. Prescribers or Authorized Representative Signature Printed Name Date Have the patient's HIPAA consent on file? YES NO PRESCRIBER INFORMATION *To be completed by the Prescribing Physician or Authorized Representative Prescriber Name: NPI #: Facility Name: Phone #: ( ) Address: City: State: Zip Code: Authorized Representative: Phone #: ( ) Fax #: ( ) REQUESTED MEDICATION *This serves as Patient Script for 90 Day Supply [Physician Signature Required] LANOXIN.0625 mg Qty: # of Refills: SIG: LANOXIN.125 mg Qty: # of Refills: SIG: LANOXIN.1875 mg Qty: # of Refills: SIG: LANOXIN.25 mg Qty: # of Refills: SIG: NILANDRON 150 mg Qty: # of Refills: SI Title: *Prescribing Physicians Signature is Required I represent that all the information provided about this patient is complete, accurate and consistent with applicable privacy laws and regulations. I certify that the Covis product is medically necessary for this patient and I will be supervising the patient s treatments. I understand that any information provide is for the sole use of the Program to verify patient s eligibility for participation in the patient assistance program and to otherwise administer the Covis Pharmaceuticals Inc. Patient Assistance Program (Covis PAP) and related services. If my patient is applying for patient assistance, I understand tha application to the patient assistance program does not guarantee that assistance will be obtained. I understand that Covis PAP reserves the right to change or cancel the patient assistance program at any time. I agree that Covis PAP may contact me for additional information relating to this applicatio either by fax or any other form of communication, including but not limited to e-mail and telephone. I understand that I am under no obligation to prescribe any Covis product and that I have not received nor will I receive any benefit from Covis or their agents or representatives for prescribing a Covi product. I attest that I am not on the HHS/OIG list of Excluded Individuals and that I am authorized under State law to prescribe and dispense the requested medication. My signature certifies that any prescription products received from this Program will be used for the above named patient only and wi not be resold nor offered for sale, trade or barter and will not be returned for credit, nor will payment be sought from any payor, patient or other source for product received from the Program. I agree to participate in any recall of the product initiated by the manufacturer. Covis Pharmaceuticals, Inc. understands your information is private. Any information you provide will only be used by Covis PAP and/or their agents and parties acting on their behalf to administer the COVIS PAP program and related services, and to comply with applicable legal requirements. Prescribers Signature Printed Name Date PAP APP Rev. 05/01/14

Covis Pharmaceuticals, Inc. Patient Assistance Program 602 Beltrami Ave. NW #105 Bemidji, MN 56601 Phone: 1-877-438-9759 Fax: 1-877-438-9759 PAP@covispharma.com AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION This document authorizes the disclosure and/or use of individually identifiable health information, set forth below, consistent with federal law concerning the privacy of such information. USE AND DISCLOSURE OF HEALTH INFORMATION I hereby authorize the use or disclosure of my health information as follows: Persons/organizations authorized to use or disclose the information: My insurer, pharmacist, physician or other health care provider. Persons/organizations authorized to receive the information: Covis Pharmaceuticals, Inc. ( COVIS PAP ) and authorized employees. Purpose of requested use or disclosure: To (1) confirm my eligibility to receive medications under the Program, (2) facilitate my participation in the Program, and (3) administer the Program. This Authorization applies to the following information: Information about my prescribed medications and medical condition, including prescriptions. This Authorization may include disclosure of information relating to mental health treatment (except psychotherapy notes) only if I place my initials on the appropriate line below. I specifically authorize the release of such information to the persons listed above. EXPIRATION (initial here) Mental Health Information This Authorization expires one (1) year after I cease to participate in the Program. NOTICE OF RIGHTS AND OTHER INFORMATION I may refuse to sign this Authorization, but such refusal would cause me to be ineligible to participate in the Program. I may revoke this Authorization at any time by calling 1-877-438-9759 and mailing a written revocation, signed by me or on my behalf, to COVIS PAP 602 Beltrami Ave. NW #105, Bemidji, MN 56601. My revocation will be effective upon receipt, but will not be effective to the extent that the requestor or others have acted in reliance upon this Authorization. Revocation of this Authorization would cause me to be ineligible for further participation in the Program. I understand that once health information about me has been disclosed in reliance upon this Authorization, the information may no longer be protected by federal privacy laws and may be further disclosed. I have a right to receive a copy of this Authorization. Patient Signature Date Relationship (if other than patient) HIPPA Rev. 05/01/14