NeedyMeds

1 Thank you for downloading this patient assistance document from NeedyMeds . We hope this program will help you get the medicine you - Send your completed application to address on the form, NOT to NeedyMeds . 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 anyhealth condition. If you are going through chemo treatment for cancer, there are programs that canhelp with wig costs and scalp-cooling products. We also list resources for free diabetes testingsupplies, caregiver lodging support, and much more.

2 Free, Low Cost, and Sliding Scale Clinics This popular collection contains information on18,000+ free, low cost, and sliding scale medical and dental clinics across the It s a greatresource 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-savingopportunities 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 beeligible for financial assistance if you meet certain , 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.

3 To date, our drug discount card has saved patients over $244,000,000. Check out the next page to learn 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 for using NeedyMeds ! Please let us know if we can do anything else to help you afford the costs of your healthcare. Rich Sagall, MDRichard J. Sagall, MD President, help with the cost of Box 219 Gloucester, MA 01931 Helpline: 1-800-503-6897 Email: 020750RX PCN: NMedsRX GRP: PDFPDFID: NMNA019309901930 This is a drug discount program, not an insurance the card and save Save up to 80% on medications* Use at over 65,000 pharmaciesnationwide 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 deductibleWhat if I have insurance?

4 Anyone can use the card, but it can t be combined with state or federal 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 holeWhat will receive a discount?All prescription medications are eligible for savings, including over-the-counter medicines and medical supplies written as a prescription, as well as human-equivalent pet medicationswith a prescription by a can also save up to 40% off durable medical equipment, including canes, crutches, splints, incontinence supplies and more. You can also save on diabetic supplies such as glucose meters, test strips, lancets and diabetic shoes. Visit to learn card is not valid in combination with insurance plans, including Medicare, Medicaid or any state or federal prescription insurance.

5 The card can be used only if you decide not to use your government-sponsored drug plan for your : You may use this card at any of over 65,000 participating pharmacies to save on all prescription medicines. You cannot use this card with Medicare including part D, Medicaid, or any other state or federal programs unless you choose not to use your government-sponsored program. In addition, you cannot use this card with any health insurance program, but you can use it in place of your insurance if the card offers a better price. For questions call 1-888-602-2978 or visit Drug Discount DISCOUNT obtain a plastic drug discount card, send a self-addressed, stamped envelope to: NeedyMeds Drug Discount CardPO Box 219 Gloucester, MA 01931 Customer Care1-888-602-2978 Pharmacist: Administered by Medical Security Company, LLC, Tucson, AZ.

6 Pharmacy Help Desk: 1-800-404-1031.* Average savings of 60%, with potential savings of up to 80% or more (based on 2018 national program savings data).All prescription medications are eligible for is a drug discount program, not an insurance plan. Discounts are available exclusively through participating pharmacies. The range of the discounts will vary depending on the type of prescription and the pharmacy chosen. This program does not make payments directly to pharmacies. Users are required to pay for all prescription purchases. Cannot be used in conjunction with insurance. You may call 1-888-602-2978 with questions or concerns or to obtain further information. 2611 Internet Blvd, Suite 105, Frisco, TX 75034 877-968-7233 Fax 214-570-3621 Private and Confidential when completed Page 1 of 5 V08062018 Patient Enrollment Application Welcome to Good Days, a non-profit organization whose financial assistance programs provide thousands of individuals diagnosed with life-altering diseases the opportunity to get the medications they need to help improve their quality of life.

7 In order for us to begin the process of qualifying you for financial assistance, please complete the enclosed application and return it to Good Days, along with copies of your insurance card(s). Completed applications can be received via mail or fax. Upon receipt of your completed application, Good Days will determine if you are eligible for financial assistance based on our Program Guidelines and subject to available funding. To verify household size and household income Good Days will perform a soft inquiry with a third party vendor in order to determine eligibility. This inquiry can only be viewed by you (the patient) on your credit history and will not affect your credit score. We will advise you and/or your medication provider of the final outcome.

8 If you qualify and if funding is available, we will provide you with financial assistance for the remainder of the calendar year. We will also provide you with a username and password so that you may freely access our therapy management portal found at Please understand that all approvals are based on available funding and are approved on a first-come, first-served basis. Receipt of application does not guarantee funding Please call us toll-free at (877) 968-7233 if you have any questions or need assistance filling out the following enrollment forms. Sincerely, Good Days, A Non-Profit Organization 2611 Internet Blvd, Suite 105 Frisco, TX 75034 877-968-7233 Fax 214-570-3621 Private and Confidential when completed Page 2 of 5 V08262019 Required Documentation & Submission Options Documentation Required 1.

9 Pages 3-5 signed and dated where applicable along with copies household income documentation. 2. A copy of the front and back of the patient s insurance cards 3. Income Verification: Good Days and its authorized third party agents will use your demographic information, including but not limited to, Social Security Number, Date of Birth, Name, and/or Address as needed to access your credit information and information derived from public and other sources to estimate your income in conjunction with the eligibility determination process. As a soft credit inquiry, this does not impact your credit score. Good Days and its authorized third party agents reserve the right to ask for additional documents and information at any time.

10 Submission Options 1. FAX: (214) 570-3621 2. MAIL: Good Days Attn: Enrollment 2611 Internet Blvd, Suite 105 Frisco, TX 75034