PRESCRIPTION SAVINGS CARD

First NUVIGIL Prescription FREE*

Refills as low as $5*

FOR PHARMACISTS
First Prescription is FREE*
On the first fill, your patient will receive up to 30 NUVIGIL tablets at no cost, subject to terms and limitations.

FOR PATIENTS

Refills as low as $5*
On all future NUVIGIL fills, your patient’s out-of-pocket expense will be as low as $5 for each prescription refill with a maximum savings of up to $50 per prescription.

INSURED PATIENT BILLING Submit a primary claim to your patient’s insurance, and then submit a secondary coordination of benefits (COB) claim to AlphaScrip. BIN: 610600 PCN: AS Group and ID numbers: located on the card PRIOR AUTHORIZATION If your insured patient’s insurance provider denied the primary claim due to a Prior Authorization (PA) requirement, please initiate the PA process to help your patient save on future NUVIGIL prescriptions If you have questions regarding prior authorization or need forms to assist your patient initiate the prior authorization process, please go to CoverMyMeds.com for assistance PATIENTS WITHOUT INSURANCE COVERAGE FOR NUVIGIL Submit a primary claim to AlphaScrip using Other Coverage Code: 00 or 01 BIN: 610600 PCN: AS Group and ID numbers: located on the card For assistance or questions regarding pharmacy billing, please contact the AlphaScrip Pharmacy Help Desk at 1-877-274-3244. The correct Other Coverage Code is required (see below). Editing the Other Coverage Code may be necessary. 03: if primary insurance has denied coverage or 08: to reduce the patient’s primary co-pay expense

First Prescription FREE*
If your doctor prescribes NUVIGIL for you, present this page, including the NUVIGIL Prescription Savings Card, and your first prescription for NUVIGIL to any participating retail pharmacy and receive your first prescription FREE (up to 30 tablets).

Refills as low as $5*
Present the NUVIGIL Prescription Savings Card to your pharmacist and pay as little as $5 per refill on future prescriptions (maximum savings of up to $50 per prescription). Patients without insurance coverage will receive only $50 off the pharmacy price of future prescriptions.

IMPORTANT: Please be sure to bring this page and your NUVIGIL prescription to your pharmacist when you fill your first prescription. It contains important instructions that the pharmacist needs in order to help you receive your first 30 NUVIGIL tablets at no cost. Please note that this offer cannot be redeemed by patients eligible for Medicare (including Medicare Advantage or Part D prescription drug plans), Medicaid, or other public payment programs.

PRESCRIPTION SAVINGS
CARD
YOUR OFFER: 1st Prescription FREE* BIN: PCN: GROUP: ID: Refills as low as $5* 610600 AS 744 74401495223

Pharmacist Certification and Agreement: By accepting and redeeming this offer, the pharmacist certifies that (i) NUVIGIL has been dispensed to a patient eligible for this offer in accordance with the Terms and Limitations below; and (ii) participation in this program complies with all applicable laws and contractual or other obligations as a pharmacy provider. Pharmacist agrees to accept the reimbursement offered for the first prescription under this offer and not charge the patient any amounts over and above the offered reimbursement. If submitting a claim under coverage code 00 or 01, pharmacist certifies that the patient does not have insurance coverage for NUVIGIL. Terms and Limitations: Offer expires 12/31/2015. Valid only in the United States at participating retail pharmacies and cannot be redeemed at government-subsidized clinics. Offer must be accompanied by a valid prescription for NUVIGIL. Void where prohibited by law. No substitutions permitted. Offer not valid for patients eligible for coverage for NUVIGIL under Medicare (including Medicare Advantage or Part D Prescription Drug Plans), Medicaid or other public payment programs (e.g., TRICARE, or any state program). Depending upon the nature and terms of your relationship with insurance carriers, you will report offer redemption to the insurance carrier if required. Offer not valid for prescriptions reimbursed in full (including co-pay) by any third party payor. Offer cannot be combined with any other voucher, certificate, coupon, rebate, or similar offer. It is illegal for any person to sell, purchase, or trade; or to offer to sell, purchase, or trade or to counterfeit this offer. This is not an insurance program. Teva Pharmaceuticals reserves the right to rescind, revoke, or amend this offer without notice. Offer not extended on prescriptions for: • Patients using mail-order or institution-based pharmacies to fill their prescriptions, or who are federal or state government employees • Patients who are filling their prescriptions at nonparticipating pharmacies • Patients 65 and over (due to Medicare eligibility) or under age 17† Additional Terms and Limitations: • Minimum supply of 14 tablets per fill • Maximum number of card uses per month of three • One card per patient Cash value of this coupon is 1/100 of a cent.

*Limitations apply. Expires 12/31/2015

Be sure to follow all dosing instructions provided by your doctor. Ask your doctor or pharmacist if you have questions regarding your prescription. If you have any questions about the NUVIGIL Prescription Savings Card Program, or your eligibility to participate, please call the AlphaScrip Patient Hotline at 1-800-284-2966.
*Limitations apply. † Patients under age 17 are not eligible, however, if patient is 17 or older and a minor, then this offer may only be redeemed by the parent or legal guardian of the minor patient.

By redeeming this offer, patients (or the parent or legal guardian of a minor patient) and pharmacists understand and agree to comply with these Terms and Limitations.

© 2014 Cephalon, Inc., a wholly-owned subsidiary of Teva Pharmaceutical Industries Ltd. All rights reserved. NUV-40418 Mar 2014