Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need. Did you know that NeedyMeds has thousands of other free resources? Here’s a look at more ways we can help you save money on medicine and healthcare costs. Each one can be found under the “Patient Savings” tab on our website:

● Diagnosis-Based Assistance — NeedyMeds lists thousands of assistance programs for almost any health condition. If you are going through chemo treatment for cancer, there are programs that can help with wig costs and scalp-cooling products. We also list resources for free diabetes testing supplies, caregiver lodging support, and much more.

● Free, Low Cost, and Sliding Scale Clinics — This popular collection contains information on 16,000+ free, low cost, and sliding scale medical and dental clinics across the U.S. It’s a great resource if you need affordable medical treatment and don’t know where to go.

● Coupons, Rebates & More — You can use the NeedyMeds website to find nearly 2,000 cost-saving opportunities for both prescription and over-the-counter drugs and medical supplies.

● Medical Transportation — Need help getting to the doctor’s office or medical facility? You may be eligible for financial assistance if you meet certain requirements.

NeedyMeds also offers information on diagnosis-based camps and retreats, recreational programs, scholarships, government programs, $4 generic drug programs, and more. Finally, I want to tell you about the NeedyMeds Drug Discount Card. Thousands of people use this free, anonymous, and easy-to-use tool to get the best price on their medications. To date, our drug discount card has saved patients over $244,000,000. Check out the next page to learn more. Feel free to call our toll-free helpline if you have any questions. You can reach us at 1-800-503-6897 Monday-Friday, 9am-5pm Eastern Time. Thanks for using NeedyMeds! Please let us know if we can do anything else to help you afford the costs of your healthcare.

Rich Sagall, MD President, NeedyMeds

BIN: 019520RX PCN: NMEDSRX GRP: PDFPDFID: NMNA019309901930

This is a drug discount program, not an insurance plan.

Clip the card and save

• Save up to 80%

• Use at over 65,000 pharmacies nationwide including all major chains

• Share the card with friends and family

• Use the card as often as needed

• Free, no fees or registration

• Never expires

• A drug isn’t covered by your insurance

• Your insurance has no drug coverage

• You have a high drug deductible

What if I have insurance?Anyone can use the card, but it can’t be combined with insurance.

You can use the card instead of insurance if:

• You have met a low medicine cap

• The card offers a better price than your copay

• You are in the Medicare Part D donut hole

What drugs are covered?The card is good for prescription drugs, over-the-counter medicines and medical

supplies if written on a prescription blank, and pet prescription medicinespurchased at a pharmacy. You’ll save on most, but not all, prescriptions.

The card is not valid in combination with other insurance plans, including Medicare, Medicaid or any state or federal prescription insurance. The card can be used only if

you decide not to use your government-sponsored drug plan for your purchases.

Patient: Simply present this card to a participating pharmacy to receive a discount on your prescription. Patients who have Medicare, including Part D, Medicaid or any state or federal prescription insurance can only use this card if they choose not to use their government-sponsored drug plan for their purchase. The card is not valid in combination with those programs. For questions concerning the card, call 1-888-602-2978 or visit www.drugdiscountcardinfo.com.Pharmacist: Card must be presented to receive program benefits. Clear system of prior cardholder information associated with this universal cardholder ID. For processing questions, call Argus Health Systems at 1-866-921-7286.

NeedyMeds Drug Discount Cardwww.needymeds.org

DRUG DISCOUNT CARD

NeedyMedsNeedyMeds.org

To obtain a plastic drug discount card, send a self-addressed stamped envelope to:

NeedyMeds-PAPPO Box 219

Gloucester, MA 01931

MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM

PATIENT MUST COMPLETE THIS SIDE.

SECTION 1: COMPLETE THE PATIENT INFORMATION BELOW. PLEASE PRINT IN LEGIBLE CAPITAL LETTERS

Patient’s First Name M.I.

Last Name

Address Apt. No.

City State ZIP

Phone Date of Birth Gender: Male Female

Provide an e-mail address if you would like to be notified with an acknowledgement of enrollment form receipt

List current annual gross household income below. Indicate the source(s) of your income by checking all boxes that apply.

Total Annual Income $ No. of Household Members (including patient)

Social Security Benefits (SS, SSI, SSDI) Wages

Interest/Dividends Pension Unemployment Compensation

Please list other income source(s) I would like my product shipped to: My Home My Physician’s Office

Do you have prescription coverage? Yes No If yes, please check all boxes that apply.

Medicare Medicaid State Pharmacy

Employer Medicare Part D Private Policy

Other (e.g. Medicare Supplement)

If other, please complete

Insurance Carrier Phone No.

Policy ID Group No.

Applicant Declarations and AuthorizationI certify that all of the information provided in this application, including household income, is complete and accurate. I understand that program assistance will terminate if the program becomes aware of any fraud or if this medication is no longer prescribed for me. I understand that completing this application does not ensure that I will qualify for this program. I certify that I cannot afford this medication. I certify that I will not seek reimbursement or credit for this prescription from any insurer, health plan, or government program. If I am a member of a Medicare Part D plan, I will not seek to have this prescription or any cost associated with it counted as part of my out-of-pocket cost for prescription drugs. I understand that Merck PAP reserves the right to modify the application form, modify or discontinue this program, or terminate assistance at any time and without notice. I authorize Merck PAP and its affiliates to forward this prescription to a dispensing pharmacy on my behalf. Merck PAP is not acting as a dispensing pharmacy. Merck PAP is not responsible for verifying any information contained in Section 2, including without limitation allergies, medical conditions, or other medications being taken by me. With respect to this application, I understand that only the dispensing pharmacy will be responsible for the information contained in Section 2 of this application form.

Patient’s Original Signature _________________________ Date

Applicant Authorization for Use and Disclosure of Personal Health InformationI understand that in order for the Merck Patient Assistance Program, Inc. (Merck PAP) to provide me with assistance, it will need to obtain, review, use, and disclose my personal health information (PHI), including information relating to my medical condition and information on my application form. I agree to allow the Merck PAP Program to contact me via mail, telephone or email to carry out these services. I authorize my physician, pharmacy, and my health plan(s) to disclose my PHI to Merck PAP and its administrators as necessary to complete the Merck PAP application process or to verify my application. I understand that my name, address, and any other personal identifying information provided in my application will be available to Merck PAP and its affiliates. I understand that my PHI disclosed under this application may no longer be protected by privacy laws and may be re-disclosed by Merck PAP only for the purposes described here. I understand that I if I don’t provide this Authorization, I won’t be able to obtain assistance from Merck PAP. I understand that I may cancel this Authorization at any time by mailing a written request for such cancellation to my prescribing physician and Merck PAP, and the cancellation will not apply to any information already used or disclosed pursuant to this Authorization. If I do not cancel this Authorization, the Authorization will expire 15 months from the date signed below. I also understand that information concerning program participants may be summarized for statistical or other purposes and provided to Merck PAP, but that any such summary shall be of de-identified data and shall not disclose, nor be able to be used to disclose, my identity. I have read this document or have had it explained to me. I understand that I may request a copy of this Authorization once it has been signed.

Patient’s Original Signature _________________________ Date

Please complete all information (both sides). Incomplete forms will be returned.

M M D D Y Y Y Y

M M D D Y Y Y Y

M M D D Y Y Y Y

PO Box 690Horsham, PA 19044-9979

For inquiries, please call 800-727-5400

Use a Black or Blue Pen

*You do not have to be a US citizen. Physician must complete Sections 2 and 3 on the back of this form. Merckhelps.com

SIGN

SIGN

Before mailing the enrollment form, please check to make sure:

• All information is completed on both sides of the enrollment form

• You signed in both areas in Section 1

• Your healthcare provider/physician/prescriber signed in both areas noted in Section 2 and Section 3

• You enclosed the Merck Patient Assistance Program enrollment form within the envelope

• Prescriptions may not exceed a 90-day supply at a time (maximum of 3 refills)

• Patient’s prescription will be sent to the patient’s home address unless otherwise requested by the patient in Section 1 of the application.

For additional information on this and other Merck Patient Assistance Programs, please visit merckhelps.com.

US Resident*

Yes No

SIGN

SIGN

THIS IS THE PRESCRIPTION. PLEASE DO NOT SUBMIT A PRESCRIPTION SEPARATE FROM THIS APPLICATION.

Patient’s First Name M.I.

Last Name

Date of Birth

Product Name Strength Quantity Directions Refill (1, 2, or 3) Times

Product Name Strength Quantity Directions Refill (1, 2, or 3) Times

Product Name Strength Quantity Directions Refill (1, 2, or 3) Times

Physician/Prescriber State License Number Date

Dispense As Written: Physician/Prescriber’s Signature _______________________________ (We cannot accept signature stamps)

ALLERGIES: None Aspirin Codeine Iodine Penicillin Sulfa Other __________________________________

MEDICAL CONDITIONS: None Asthma Glaucoma Heart High BP Ulcer Other __________________________________

CURRENT MEDICATION(S) BEING TAKEN BY THE PATIENT: ________________________________________________________________________

SECTION 3: PHYSICIAN/PRESCRIBER MUST COMPLETE, SIGN AND DATE.

Physician’s First Name M.I.

Physician’s Last Name

Professional Designation

Name of Facililty/Site

Mailing Address (PO Boxes not permitted)

Street Address 1

Street Address 2

City State ZIP

Office Phone Ext.

Secure Fax

Office Contact Name ____________________________________ E-mail Address _________________________________________________

Physician/Prescriber Attestation

I certify that this prescription is medically appropriate for this patient and that I will be supervising the patient’s treatments. I verify that the information provided is complete and accurate to the best of my knowledge. I authorize the Merck PAP, its affiliated companies, or its subcontractors to forward this prescription to a dispensing pharmacy on behalf of myself and my patient. I understand that Merck PAP reserves the right to modify or discontinue this program at this facility/practice, or terminate assistance at any time and without notice.

Physician’s/Prescriber’s Original Signature _____________________________________ Date

CORP-1083762-0001 10/13 Merckhelps.comTear here, place enrollment form in envelope, and mail.

- -

- -

M M D D Y Y Y Y

M M D D Y Y Y Y

PHYSICIAN/PRESCRIBER MUST COMPLETE THIS SIDE.

SECTION 2: COMPLETE THE PRESCRIPTION AND PRODUCT INFORMATION BELOW. PLEASE PRINT IN LEGIBLE CAPITAL LETTERS

Use a Black or Blue Pen

This form should not be tampered with or revised in anyway. Only originals with ink signatures will be accepted.

To report an adverse event to a specific Merck product, including death due to any cause, please contact the Merck National Service Center at 1-800-444-2080.