PROGRAM TERMS, CONDITIONS, AND ELIGIBILITY CRITERIA

1. This offer is valid only for eligible patients and is good for use only with a valid prescription for GEMTESA at the time the prescription is filled by the pharmacist and dispensed to the patient.
2. Depending on your insurance coverage:
   1. Most commercially insured patients who have coverage for GEMTESA pay as little as $10 for each 30-day supply or as little as $0 for each 90-day supply between January 1, 2023 and December 31, 2024. Maximum savings limit for covered claims is $380 for each 30-day supply or $1,140 for each 90-day supply; final patient out-of-pocket expense will vary.
   2. Most commercially insured patients who do not have coverage for GEMTESA pay as little as $95 for each 30-day supply. Maximum savings limit for not-covered claims is $415 for each 30-day supply; final out-of-pocket expense will vary.
3. This card is valid for up to 12 prescription fills for a 30-day supply or 4 prescription fills for a 90-day supply.
4. This card expires one-year from activation date.
5. This offer is not valid for use by patients enrolled in Medicare, Medicaid, or other federal or state programs (including any state pharmaceutical assistance programs), or private indemnity or HMO Insurance plans that reimburse the patient for the entire cost of the prescription drugs. Patients may not use this offer if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. This offer is not valid for cash-paying patients.
6. Sumitomo Pharma reserves the right to rescind, revoke, or amend this offer without notice.
7. Offer good only in the USA, including Puerto Rico, at participating retail pharmacies.
8. Void where prohibited by law, taxed, or restricted.
9. This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law.
10. This card has no cash value and may not be used in combination with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription.
11. This offer is not health insurance.
12. By redeeming this card, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer.

For questions about this program please call 1-833-876-8268.

Pharmacist Instructions for a patient with an eligible third-party payer: When you redeem this card, you certify that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government health insurance programs for this prescription.

• Submit the claim to the primary third-party payer first and then submit the balance due as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code, (e.g. 3 or 8). The patient's out-of-pocket expense will be reduced up to the maximum savings limit for the program.
• Valid Other Coverage Code required. For any questions regarding online processing, please call the Help Desk at 1-347-682-2470.

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