BIN #: PC#: GRP#: ID#:

BIN #: PC#: GRP#: ID#:

a Limitations apply. See reverse for details.

Eligible commercially insured patients may also receive their oral genericsumatriptan prescription at NO ADDITIONAL COSTa

004682CNEC6900600358884537532

004682CNEC6900600458884537532

Powered by:Change Healthcare

Eligible commercially insured patientsPAY AS LITTLE AS

$0on their prescription with the ZEMBRACE SymTouch Dual Savings Carda

ZEMBRACE® SymTouch® (sumatriptan injection) 3 mg OFFERPatient Instructions: Redeem this coupon ONLY when accompanied by a valid prescription for ZEMBRACE SymTouch. Eligible patients pay as little as $0 for each prescription, however maximum reimbursement limits apply. This card must be presented at the time of fill for instant savings. Offer is good for commercially insured patients only. This side of the card must be redeemed first in order to receive up to $10 off your Sumatriptan prescription with the other side of the card. This coupon is good for up to 12 uses and is not transferable. Pharmacist instructions for a patient with an Eligible Third Party: Submit the claim to the primary Third Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code, (e.g. 8). Maximum reimbursement limits apply. Reimbursement will be received from Change Healthcare.For Patients whose insurance plan does not cover product: Submit the claim from the primary Third Party Payer to Change Healthcare as a secondary payer COB with patient responsibility amount and process using Other Coverage Code (e.g. 3). Maximum reimbursement limits apply. Reimbursement will be received from Change Healthcare. Valid Other Coverage Code required. For any questions regarding Change Healthcare online processing, please call the Help Desk at 1-800-422-5604.For offer details and patients with questions, please call 1-844-247-3983. Please consult Full Prescribing Information for ZEMBRACE SymTouch. Not valid for cash-paying patients or patients reimbursed by federal health care programs, including Medicare, Medicaid, TriCare, the Department of Veterans Affairs, state maternal and child health block grant programs under 42 U.S.C. 701 et. seq. state social service block grant programs under 42 U.S.C. section 1397 et. seq. or any other similar federal or state healthcare program. Void where prohibited by law, taxed or restricted. Void outside the United States. Patient is responsible for reporting receipt of card program rewards to any private insurer that pays for or reimburses any part of the prescriptions filled with this card. Void if reproduced. It is illegal for any person to sell, purchase, or trade, or offer to sell, purchase or trade, or to counterfeit this card. Offer expires 12 months after initial use. Offer may be rescinded, revoked or amended at any time without notice.

© 2017 PSKW, LLC.ZEMBRACE and Symtouch are registered trademarks of Upsher-Smith Laboratories, LLC. All other marks are property of their respective owners. © 2019 Upsher-Smith Laboratories, LLC PM-000430.01

Oral Sumatriptan OFFERPatient Instructions: Redeem this coupon ONLY when accompanied by a valid prescription for oral sumatriptan. Eligible patients will receive up to $10 off their sumatriptan prescription. Offer is good for commercially insured patients only. This side of the card will work after processing a claim on the ZEMBRACE SymTouch side of the card. Oral sumatriptan offer is void in MI.Pharmacist instructions for a patient with an Eligible Third Party: Submit the claim to the primary Third Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code, (e.g. 8). The patient pay amount submitted will be reduced by up to $10 and reimbursement will be received from Change Healthcare.Valid Other Coverage Code required. For any questions regarding Change Healthcare online processing, please call the Help Desk at 1-800-422-5604.Patients with questions should call 1-844-247-3983. Generic sumatriptan offer void without use of ZEMBRACE SymTouch offer. See exclusions above. Oral sumatriptan offer is void in MI.