Copay Savings Card Terms and Conditions

This offer is valid only for eligible patients. By using this card, you acknowledge that you currently meet the following eligibility requirements:

• You are 18 years of age or older.
• You have a valid prescription for KYNMOBI.
• You are not enrolled in any state or federal health care program, including, but not limited to, Medicare (including Medicare Advantage), Medicaid (including managed Medicaid plans), Medigap, VA, DOD or TRICARE. In addition, you are not Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees.

Additional Terms and Conditions Include:

• The offer applies only to prescriptions filled before the program expires or terminates.
• The copay prescription shall not be submitted for reimbursement to any federal or state health care program, including Medicare (including Medicare Advantage), Medicaid (including managed Medicaid plans), Medigap, VA, DOD, TRICARE, or an employer-sponsored health plan or prescription drug benefit program for Medicare-eligible retirees.
• Individual copay amounts may vary. Eligible patients with commercial insurance may pay as little as $15 per 30-count carton. Eligible cash paying patients may pay as little as $195 per 30-count carton. A maximum benefit limit may also apply. If the patient’s total out-of-pocket pharmacy bill exceeds the cap established by Sunovion, the patient will be responsible for the additional balance. Patients should confirm their out-of-pocket costs.
• This program is not health insurance.
• The amount of the benefit will not exceed your out-of-pocket expenses.
• You must deduct the value of the savings received under this program from any reimbursement request submitted to your insurance plan, either directly or on your behalf.
• Offer limited to one per person and may not be used with any other offer.
• A minimum patient requirement for participation in the program is an activated Program ID number.
• Only an original (no copies) or printout of the Copay Savings Card must be presented to participating pharmacies.
• For California and Massachusetts residents, benefits pursuant to this Copay Savings Card will terminate automatically upon the introduction of a therapeutically equivalent product.
• Offer valid only in the United States and Puerto Rico. Void where prohibited by law, taxed or restricted.
• Certain information related to your use of the Copay Savings Card may be collected, analyzed, and shared with Sunovion for market research and other purposes related to assess Sunovion's programs. Information shared with Sunovion will be aggregated and deidentified; it will be combined with other data related to other Copay Savings Card redemptions and will not identify you.

Sunovion reserves the right to rescind, revoke, or amend this offer at any time without notice. This offer is not transferable and may not be sold, purchased or traded, or offered for sale, purchase, or trade. The offer has no cash value and may not be combined with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription. The offer is intended to comply with all applicable laws and regulations, including, without limitation, the federal Anti-Kickback Statute, its implementing regulations, and agency guidance interpreting the federal Anti-Kickback Statute; the government pricing laws; and all other applicable laws.

To the Patient: You must present this Copay Savings Card to the pharmacist along with your valid prescription to participate in this program. If you have any questions regarding your KYNMOBI Copay Savings Card eligibility or benefits, or if you wish to discontinue your participation, call the KYNMOBI Savings Card program at 1-844-KYNMOBI (596-6624) anytime between 8:00 AM-8:00 PM EST Monday-Friday. By using this Copay Savings Card, you are certifying that you understand the enclosed program rules, regulations, and terms and conditions; you are eligible to participate in this program, including that you are not enrolled in any federal or state health care program; you have not submitted and will not submit a claim for reimbursement to, or otherwise seek payment from, any federal, state or other governmental program for this prescription or where otherwise prohibited by law in your state; you will comply with any obligations or requirements imposed by your insurance plan; and you will otherwise comply with the terms mentioned herein.

To the Pharmacist: When you use this Copay Savings Card, you are certifying that you have appropriately inquired regarding the patient’s insurance coverage and have not submitted and will not submit a claim for reimbursement to, or otherwise seek payment from, any federal or state health care program for this prescription.

• Submit transaction to McKesson Corporation using BIN #610524.
• If primary commercial prescription exists, input card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response.
• Acceptance of this Copay Savings Card and your submission of claims to the program are subject to the LoyaltyScript^® program Terms and Conditions posted at www.mckesson.com/mprstnc.
• Patient is not eligible if prescriptions are paid in part or full by any state or federally funded health care programs, including but not limited to Medicare (including Medicare Advantage) or Medicaid (including managed Medicaid plans), Medigap, VA, DOD, TRICARE, or where prohibited by law. In addition, patients may not use the offer if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees.
• The LOYALTYSCRIPT^® Card is not valid for use with any other prescription drug discount or cash cards for KYNMOBI. Claims submitted utilizing the program are subject to audit or validation.
• For questions regarding setup, claim transmission, patient eligibility, or other issues, call the KYNMOBI Savings Card program at 1-844-KYNMOBI (1-844-596-6624) from 8:00 AM–8:00 PM (EST), Monday through Friday.

Sunovion Pharmaceuticals Inc. reserves the right to rescind, revoke, or amend this offer at any time.