savings card

PATIENT INSTRUCTIONS:

You must present this card to the pharmacist along with your prescription for Adhansia XR (methylphenidate HCl) extended-release capsules, CII to participate in this program. If you have any questions regarding your eligibility or benefits, or if you wish to discontinue your participation, call the Adhansia XR Patient Savings Program at 1-866-420-77191-866-420-7719 (available 24 hours/day except major holidays). When you use this card, you are certifying that you understand the program rules, regulations, and terms and conditions.

TO THE PHARMACIST:

Savings Card can only be used when accompanied by a valid prescription for Adhansia XR. For insured patients, process a Coordination of Benefits (COB) claim using the patient’s prescription insurance for the primary claim. Submit a secondary claim to DST (formerly Argus), using BIN: 600428/PCN: 06780000. Return card to patient and remind them to retain for future use. For questions regarding claim transmission, please call the TrialCard Help Desk at 1-866-420-77191-866-420-7719. By submitting this card for reimbursement you certify that:

• You have dispensed the covered drug to an eligible patient in accordance with the terms of the card and accompanying prescription
• Other than TrialCard, you have not submitted and will not submit a claim for reimbursement to any Third Party Payor that prohibits use of the card, including Medicare, Medicaid, any similar federal or state healthcare program, or any patient assistance programs; and
• Your participation in this program is consistent with all applicable laws and with all of your contractual or other obligations

Eligibility Requirements

This card is valid only for patients with commercial (private or non-governmental) insurance. It is not valid for patients (i) who are government beneficiaries or whose prescription drugs are eligible to be reimbursed, in whole or in part, by any Federal Health Care Program, as that term is defined at 42 U.S.C. §1320a-7b(f), including Medicaid, Medicare, a Medicare Part D or Medicare Advantage plan, TRICARE, CHAMPUS, Puerto Rico Government Health Insurance Plan, or any other state or federal healthcare program; (ii) who are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees; or (iii) who reside in a state where the card is prohibited.

Terms and Conditions

You must meet eligibility requirements. This card is only available with a valid prescription. The card is not valid for medications you received for free or that are eligible to be reimbursed by private insurance plans or any other healthcare pharmaceutical assistance programs that reimburse you for the entire cost of your medications. You agree not to seek reimbursement for all or any part of the benefit received through this offer. You agree to report your use of this card to any third party that reimburses you or pays for any part of the prescription price. You additionally agree that you will not submit any portion of the product dispensed pursuant to this card to a federal or state healthcare program for purposes of counting it toward your out-of-pocket expenses. This card has no cash value and is not valid with any other program, discount, or incentive involving the covered medication. Use of this card must be consistent with all relevant health insurance requirements and payer agreements. Participating patients, pharmacies, physician offices, and hospitals are obligated to inform third-party payers about the use of the card as provided for under the applicable insurance or as otherwise required by contract or law. This card may not be sold, purchased, traded, or offered for sale, purchase, or trade. This card is limited to one per person during the offering period and is not transferable. This offer is not contingent upon any past, present, or future purchases of the covered medication or any other product, and this offer may be rescinded, revoked, or amended without notice. No reproductions. This card is not health insurance or a benefit plan. This card is void where prohibited or where restricted beyond the terms herein. Maximum benefits apply. For questions about this card, call 1-866-420-77191-866-420-7719.

Adlon Therapeutics L.P. reserves the right to rescind, revoke, or amend this offer without notice at any time.