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

1 Patient Information

Patient Authorization

Name

DOB Sex M F

Address

City State Zip

E-mail

Preferred Language (if not English)

Patient Signature/Legal Representative Patient Signature/Legal Representative

Preferred Phone

Alternate Phone

Best Hours to Call

Voice Mail Message Preferred Phone Alternate Phone No Message

Text Message Preferred Phone Alternate Phone No Message

Relationship to Patient (If signed by someone other than the patient, please describe your authority to sign on behalf of the patient.)

2 Insurance Please attach copies of front and back of primary and prescription cards.

Primary Insurance No insurance

Insurance Phone

Policy ID # Group #

Policy Holder Name (First/Last)

Relationship to Patient

Rx Insurance (if different)

Rx Insurance Phone

Policy ID # Group #

Rx Bin # Rx PCN #

Please fill out Section 6 if you do not have health insurance.

My signature certifies that the person named on this form is my patient; the information provided on this application, to the best of my knowledge, is complete and accurate; and that therapy with DUPIXENT is medically necessary. I understand that my patient’s information provided to Regeneron Pharmaceuticals, Inc., Sanofi US, and their affiliates and agents (the “Alliance”) is for the use of DUPIXENT MyWay™ solely to verify my patient’s insurance coverage; to assess, if applicable, my patient’s eligibility for patient assistance and other support programs; and to otherwise administer DUPIXENT MyWay for the patient. I request DUPIXENT MyWay to conduct a benefits investigation for my patient and authorize DUPIXENT MyWay to act on my behalf for the limited purpose of transmitting this prescription to the appropriate pharmacy designated by the patient per their benefit plan. If this prescription is not so designated, DUPIXENT MyWay is authorized to transmit this prescription to a network pharmacy it selects or to the pharmacy I have indicated. I consent to DUPIXENT MyWay contacting me by fax, mail, or e-mail to provide additional information about DUPIXENT injection or DUPIXENT MyWay. I agree that DUPIXENT MyWay may revise, change, or terminate any program services at any time without notice to me.

I have read and agree to the Patient Certifications included in Section 7I have read and agree to the Patient Authorization to Use and Disclose Health Information in Section 8

By checking this box, I indicate that I have read the Text Messaging Consent in Section 7 and expressly consent to receive text messages by or on behalf of the Program.

3 4Prescriber Prescription

Prescriber Name

Site/Facility Name

Prescriber NPI # Group Tax ID #

Address

City State Zip

Specialty State License #

Office Contact

E-mail

Phone Fax

Rx DUPIXENT (dupilumab) 300 mg/2 mL Prefilled syringe 2-Pack

SIG: 2 injections subcutaneously on Day 1 Qty: 1

INITIAL DOSE: 600 mg # of 2-packs:

page 1/4

I have already sent this prescription to the specialty pharmacy above. By checking this box, I acknowledge this pharmacy’s role in seeking to secure coverage on the patient’s behalf.

My preferred specialty pharmacy is:

Preferred Specialty Pharmacy Name

Phone Fax

Fax 1-844-387-9370 Phone 1-844-DUPIXENT [1-844-387-4936] Option 1

To prevent delays, complete all fields and FAX ALL 4 PAGES to number above. For additional assistance, call us at number above M–F, 8 AM – 9 PM ET

Enrollment Form

MM DD YYYYMM DD YYYY

SIG: 1 injection every 2 weeks starting on Day 15

SIG:

Qty:

Qty:

Frequency:

Known drug allergies

Dose:

MAINTENANCE: 300 mg

MAINTENANCE: Other

Refills:

Refills:

NY state prescribers, please submit prescription on an original NY State prescription blank.

Prescriber Signature (No stamps) Dispense as written MM DD YYYY

/ /

/ // /

/ /

Complete entire form and fax ALL 4 PAGES to DUPIXENT MyWay at 1-844-387-9370

Please click here for full Prescribing Information.

US-DAD-14043, US.DUP.17.02.026

Patient Name

Prescriber Name NPI#

5 Clinical

6 Household Income Required if enrolling in the DUPIXENT MyWay Patient Assistance Program

How many people live in your household?

Total annual household income $0 to $100,000 Greater than $100,000(Includes salary/wages, Social Security income, unemployment insurance benefits, disability income, any other income for the household.)

To qualify for the DUPIXENT MyWay™ Patient Assistance program, I understand that I must not have confirmed insurance coverage for DUPIXENT and I must meet certain income and other eligibility requirements. DUPIXENT MyWay may ask for proof of income at any time for the purpose of audit/verification. If requested, I agree to provide proof of income within thirty (30) days of the request.

Continuation in the program is conditioned upon timely verification of income. In addition, I agree to notify DUPIXENT MyWay if my insurance situation changes.

page 2/4

To prevent delays, complete all fields and FAX ALL 4 PAGES to number above. For additional assistance, call us at number above M–F, 8 AM – 9 PM ET

Enrollment Form

Topical Therapies:

to

to

Topical therapies are inappropriate for this patient

Rationale:

Systemic Corticosteroids, Immunosuppressants and/or Phototherapy:

to

to

to

CURRENT AND PRIOR THERAPIES DIAGNOSIS DURATION

Patient is 18 or over

Patient has moderate to severe atopic dermatitis (AD)* that is inadequately controlled on prior or current topical therapy

Years since diagnosis:

ICD-10 code: L .20. L .20. L .20.

Systemic corticosteroids are inappropriate for this patient

Immunosuppressants are inappropriate for this patient

Phototherapy is inappropriate for this patient

Rationale:

*Moderate to severe AD is defined as moderate to severe erythema and moderate to severe papulation/infiltration.1

1. Futamura M, Leshem YA, Thomas KS, Nankervis H, Williams HC, Simpson EL. A systematic review of Investigator Global Assessment (IGA) in atopic dermatitis (AD) trials: many options, no standards. J Am Acad Dermatol. 2016;74:288-294.

SEVERITY

Sensitive areas affected (Check all that apply): hands feet face and neck genitals/groin scalp intertriginous areas other

Body Surface Area (BSA) involved: under 10% 10% or more

Please attach office chart notes relevant to therapy.

Fax 1-844-387-9370 Phone 1-844-DUPIXENT [1-844-387-4936] Option 1

Complete entire form and fax ALL 4 PAGES to DUPIXENT MyWay at 1-844-387-9370

Please click here for full Prescribing Information.

US-DAD-14043, US.DUP.17.02.026

7 Patient Certifications

* I acknowledge that by checking the Text Messaging Consent box on page 1, I expressly consent to receive text messages from or on behalf of the Program at the mobile telephone number(s) that I provide.

I confirm that I am the subscriber for the mobile telephone number(s) provided, and I agree to notify the Alliance promptly if any of my number(s) change in the future. I understand that my wireless service provider’s message and data rates may apply. I understand that I can opt out of future text messages at any time by texting SMSSTOP to 39771 from my mobile phone, and that I can get help for text messages by texting SMSHELP to 39771. I also understand that additional text messaging terms and conditions may be provided to me in the future as part of an opt-in confirmation text message. I understand that my consent is not required as a condition of purchasing any goods or services from Regeneron Pharmaceuticals, Inc., Sanofi US, or their affiliates. Message and data rates may apply.

I am enrolling in the DUPIXENT MyWay™ Program (the “Program”) and authorize Regeneron PharmaceuticaIs, Inc., Sanofi US, and their affiliates and agents (together the “Alliance”) to provide me services under the program, as described in the Program Enrollment Form and as may be added in the future. Such services include medication and adherence communications and support, medication dispensing support, coverage and financial assistance support, disease and medication education, injection training, and other support services (the “Services”).

I agree to my enrollment in the DUPIXENT MyWay Copay Card program if confirmed as eligible, understand that Copay Card information will be sent to my designated specialty pharmacy/in-network specialty pharmacy along with my prescription, and any assistance with my applicable cost-sharing or copayment for DUPIXENT® injection will be made in accordance with the Program terms and conditions.

If I am completing Section 6, I confirm my agreement with the conditions set forth in Section 6, and certify that the number of people in my household and my household income are true and accurate to the best of my knowledge.

I authorize the Alliance to contact me by mail, telephone, or e-mail, or, if I indicate my agreement and consent on page 1, by text*, with information about the Program, atopic dermatitis (AD) and products, promotions, services, and research studies, and to ask my opinion about such information and topics, including market research and disease-related surveys. I further authorize the Alliance to de-identify my health information and use it in performing research including linkage with other de-identified information the Alliance receives from other sources, education, business analytics, marketing studies or for other commercial purposes. I understand that members of the Alliance may share identifiable health information with one another in order to de-identify it for these purposes and as needed to perform the Services or to send the communications listed above (the “Communications”). I understand and agree that the Alliance may use my health information for these purposes and may share my health information with my doctors, specialty pharmacies, and insurers.

I understand that I do not have to enroll in the Program or receive the Communications, and that I can still receive DUPIXENT injection, as prescribed by my physician. I may opt out of receiving Communications, individual support services offered by the Program, including the DUPIXENT MyWay Copay Card, or opt out of the Program entirely at any time by notifying a Program representative by telephone at 1-844-387-4936 or by sending a letter to DUPIXENT MyWay, 1800 Innovation Point, Fort Mill, SC 29715. I also understand that the Services may be revised, changed, or terminated at any time.

You may keep a copy of this form for your records.

Text Messaging Consent:

Patient Name

Prescriber Name NPI#

page 3/4

Please read the following carefully, then date and sign where indicated in Section 1 of page 1

Fax 1-844-387-9370 Phone 1-844-DUPIXENT [1-844-387-4936] Option 1

Complete entire form and fax ALL 4 PAGES to DUPIXENT MyWay at 1-844-387-9370

Please click here for full Prescribing Information.

US-DAD-14043, US.DUP.17.02.026

8 Patient Authorization to Use and Disclose Health Information

I authorize my healthcare providers and staff, my health insurer, health plan or programs that provide me healthcare benefits (together, “Health Insurers”), and any specialty pharmacies that dispense my medication to disclose to Regeneron Pharmaceuticals, Inc., Sanofi US, and their affiliates and agents (together, the “Alliance”) health information about me, including information related to my medical condition and treatment, health insurance coverage and claims, prescription (including fill/refill information), and referral to and enrollment in the Program (“My Information”) for the purposes of enrolling me in and providing certain services, including:• to determine if I am eligible to participate in DUPIXENT MyWay ™ coverage assistance programs,

patient assistance programs, or other support programs (the “Program”)• to investigate my health insurance coverage for DUPIXENT® injection• to obtain prior authorization for coverage• to assist with appeals of denied claims for coverage• for the operation and administration of the Program• to refer me to, or to determine my eligibility for, other programs, foundations, or alternative sources of

funding or coverage that may be available to provide assistance to me with the costs of my medicationI understand and agree that my healthcare providers, health insurers, and specialty pharmacy(ies) may receive remuneration from the Alliance in exchange for disclosing My Information to the Alliance and/or for providing me with support services in connection with the Program.Once My Information has been disclosed to the Alliance, I understand that federal privacy laws may no longer protect it from further disclosure. However, the Alliance agrees to protect My Information by using and disclosing it only for the purposes allowed by me in this Authorization or as otherwise allowed by law. I understand that I do not have to sign this Authorization. A decision by me not to sign this Authorization will not affect my ability to obtain medical treatment, insurance coverage, access to health benefits or Alliance medications. However, if I do not sign this Authorization, I understand that I will not be able to participate in the Program. I understand that this Authorization expires 18 months from the date support is last provided under the Program, subject to applicable law, unless and until I withdraw (take back) this Authorization before then. Further, I understand that I may withdraw this Authorization at any time by mailing or faxing a written request to DUPIXENT MyWay at 1800 Innovation Point, Fort Mill, SC 29715; Fax: 1-844-387-9370. Withdrawal of this Authorization will end my participation in the Program and will not affect any disclosure of My Information based on this Authorization made before my request is received and processed by my healthcare providers and staff, my health insurers, and specialty pharmacies.I understand that I may request a copy of this Authorization.

Patient Name

Prescriber Name NPI#

(LAST PAGE) page 4/4

Please read the following carefully, then date and sign where indicated in Section 1 of page 1

Fax 1-844-387-9370 Phone 1-844-DUPIXENT [1-844-387-4936] Option 1

© 2017 Sanofi and Regeneron Pharmaceuticals, Inc. 03/2017 US-DAD-14043, US.DUP.17.02.026

Complete entire form and fax ALL 4 PAGES to DUPIXENT MyWay at 1-844-387-9370

Please click here for full Prescribing Information.