AUSTEDO^® (deutetrabenazine) tablets Copay Program Terms and Conditions:

• This AUSTEDO^® Copay Program (the “Program”) is available to eligible individuals who have a valid prescription for AUSTEDO^®. No substitutions permitted.
• Generally, eligible individuals must have commercial insurance coverage for AUSTEDO^®. However, where a commercial insurer requires a prior authorization for AUSTEDO^®, the insured individual may receive a 30 day supply of AUSTEDO^®(up to a total of three prescriptions with only one prescription per AUSTEDO^® strength or NDC) under the Program while their prior authorization is pending. If the prior authorization is approved by the commercial insurer, then the individual remains eligible for the Program. If the prior authorization is denied by the commercial insurer, then the individual is no longer eligible for this Program and may not receive any additional Program benefits. Cash-paying individuals are NOT eligible for this Program nor are individuals with commercial insurance that does not provide coverage for AUSTEDO^® (except while a prior authorization is pending as noted above).
• Where the prior authorization or approval process extends beyond 30 days, patients may not receive additional benefits under this Program while that process is pending. Other programs may be available to provide assistance to eligible patients where a coverage decision extends beyond 30 days.
• Individuals enrolled in any state or federally funded healthcare program, including but not limited to, Medicare, Medicare Advantage Plans, Medicare Part D, Medicaid, Medigap, VA, DOD, TRICARE, the Puerto Rico Government Health Insurance Plan or private health insurance plans or programs which reimburse you for the entire cost of your prescription drugs are NOT eligible for this Program.
• Individuals who are Medicare eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees (i.e. you are eligible for Medicare Part D but receive a prescription drug benefit through a former employer) are NOT eligible for this Program.
• Individuals who move from commercial to federally funded insurance will no longer be eligible for the Program.
• Eligible individuals receive a maximum annual benefit per calendar year, e.g. January 1 through December 31. Each eligible individual is responsible for their out of pocket costs for AUSTEDO^® above the Program’s maximum benefit amount. Patients enrolled in the Program will continue to be enrolled in the Program through the Program date unless they opt out of the Program or their insurance coverage changes.
• Offer expires on December 31, 2019.
• This offer is not health insurance.
• When submitting claims under this Program, individuals and their treating providers are certifying that they understand the program rules, regulations, and terms and conditions and comply with the Program terms as set forth herein. Specifically, you are certifying that a claim has not been submitted under a state or federally funded healthcare program, including but not limited to, Medicare, Medicare Advantage Plans, Medicare Part D, Medicaid, Medigap, VA, DOD, TRICARE and the Puerto Rico Government Health Insurance Plan.
• Offer valid only in the United States and the Commonwealth of Puerto Rico at participating specialty pharmacies. This offer is void in California if an AB-rated generic equivalent for the product is available. Void if copied, transferred, purchased, altered or traded, and where prohibited and restricted by law.
• Teva Pharmaceuticals reserves the right to make eligibility determinations, to set Program benefit maximums, to monitor participation, and to change, rescind, revoke, or discontinue this Program at any time without notice. Limit one Program enrollment per individual. If you have questions regarding this Program, your eligibility or benefits or if you wish to discontinue your participation, please call the AUSTEDO^® Copay Program at 1-800-887-8100.

AUS-41402 December 2018