Getting Your Prescription

To the Patient:

To redeem this offer, you must have a valid prescription for AUSTEDO^®. No substitutions permitted. Commercially insured patients with coverage for AUSTEDO^® may pay no out-of-pocket costs. Commercially insured patients whose insurer requires a prior authorization for AUSTEDO^® 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. Maximum annual benefits apply and out-of-pocket expenses may vary. Patient is responsible for costs above maximum benefit amounts. If you have any questions regarding your eligibility or benefits, please call the AUSTEDO^® Copay Program at 1-800-887-8100.

You are not eligible for this offer if your prescriptions are paid for in part or full by any state or federally funded programs, including but not limited to Medicare or Medicaid, Medigap, VA, DOD, TRICARE, or by private health benefit programs which reimburse you for the entire cost of your prescription drugs. This offer is not valid for patients who are Medicare eligible and are enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees (i.e., patients who are eligible for Medicare Part D but receive a prescription drug benefit through a former employer). You are not eligible for this offer if you are uninsured or a cash-paying patient. This offer is void in California if an AB-rated generic drug is available for the product. By redeeming this offer, you acknowledge that you are an eligible patient and you understand and agree to comply with the terms and if copied, transferred, purchased, altered or traded and where prohibited and restricted by law. conditions of this offer. Void if copied, transferred, purchased, altered or traded and where prohibited and restricted by law. Program managed by PSKW, LLC on behalf of Teva Pharmaceuticals. The parties reserve the right to change or discontinue this offer at any time without notice. This offer is not health insurance.

This offer is restricted to residents of the United States and Puerto Rico and valid only at participating pharmacies. This offer is limited to one per customer and may not be used with any other discount, coupon or offer. Offer expires December 31, 2019.

To the Pharmacist:

When you apply this offer, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental program for this prescription.

Pharmacist Instructions: Submit claim to Therapy First Plus. If primary coverage exists, input offer information as secondary coverage and transmit using the COB segment of the NCPDP transaction.

For questions regarding processing, please call the Help Desk 1-800-422-5604 .

AUS-41403 December 2018