Sunoion Support

1 1 Sunovion Support PRESCRIPTION ASSISTANCE PROGRAMH ousehold Income Information (legal guardian to complete if patient has one)1. Number of people in household: (include yourself, your spouse and any dependents)2. What is total GROSS ANNUAL household income (including Social Security, Disability, Veterans, Wages, pension benefits, etc.)? $ 3. Did the patient/guardian file a Federal Income Tax Return for previous calendar year? YES NOPlease provide us with one of the following items to show total gross annual household income: Current paycheck stubs, proof of Social Security Income, 1099 or W-2 forms for all members of household Federal Tax Return ( form 1040 or 1040EZ) for prior tax yearIf the patient has not filed a Federal Tax Return, visit to request a free Verification of Non-Filing.

2 Click on Order a Transcript or call (800) 908-9946. Use Form 4506-T and check box 7 to request verification of apply for help in affording your Utibron Neohaler (indacaterol and glycopyrrolate) Inhalation Powder prescription, please mail completed application to:Sunovion Support Prescription Assistance Program ( Program )PO Box 220285, Charlotte, NC 28222-0285or fax: (877) 850-0821 Please see Important Safety Information, including Boxed Warning on pages 4 and 5 and enclosed full Prescribing to include both your signature and that of your doctors, proof of income and the patient s prescription. If you have any questions or need help filling out this form, please contact us at (877) 850-0819 or visit InformationName: Date of Birth: Phone: ( ) Gender: M FMailing Address: City: State: Zip: Is the patient a US resident (includes Puerto Rico)?

3 YES NOIs the patient 18 years of age or older? YES NOIf Patient has a legal guardian, please complete this section:Legal Guardian(s) Name:Phone: Mailing Address:City: State: Zip: Sunovion Support Prescription Assistance Program 2017 Sunovion Pharmaceuticals Box 220285 | Charlotte, NC 28222-0285 | Phone (877) 850-0819 | Fax (877) 850-08212 Sunovion Support PRESCRIPTION ASSISTANCE PROGRAMP atient s Insurance Information1. Is the patient enrolled in Medicare/Medicaid? YES NO2. Does the patient have prescription drug coverage through any other benefit program that helps pay for prescriptionmedicine, such as private insurance or VA or military benefits, including Medicare Part D?

4 YES NOIf yes: please describe: From the Healthcare Professional (to be completed by the doctor who is prescribing the medicine)Healthcare Professional: Site contact: State License #: Facility Name: Phone: ( ) Fax: ( ) Street address: City: State: Zip: Prescription Information: Utibron Neohaler (indacaterol and glycopyrrolate) Inhalation Powder Please see Important Safety Information, including Boxed Warning on pages 4 and 5 and enclosed full Prescribing : mcg twice dailyDay Supply: 30 Days Method of delivery: Patient will pick up prescription at retail pharmacy (will receive 30 day supply/ per fill only)Number of Refills (max 11).

5 If there is a change in prescription or diagnosis of patient, Sunovion Support needs to be notified in Code (required information) J40 Bronchitis, not specified as acute or chronic J41 Simple and mucopurulent chronic bronchitis Simple chronic bronchitis Mucopurulent chronic bronchitis Mixed simple and mucopurulent chronic bronchitis J42 Unspecified chronic bronchitis J43 Emphysema Panlobular emphysema Centrilobular emphysema Other emphysema Emphysema, unspecified J44 Other chronic obstructive pulmonary disease Chronic obstructive pulmonary disease with acute lower respiratory infection Chronic obstructive pulmonary disease with acute exacerbation, unspecified Chronic obstructive pulmonary disease.

6 Unspecified J47 Bronchiectasis Sunovion Support Prescription Assistance Program 2017 Sunovion Pharmaceuticals Box 220285 | Charlotte, NC 28222-0285 | Phone (877) 850-0819 | Fax (877) 850-08213 Sunovion Support PRESCRIPTION ASSISTANCE PROGRAMYour Consent is Required to Process ApplicationI acknowledge and agree that the above information is complete and accurate. I attest that I have no prescription insurance coverage, including Medicaid, Medicare or other public or private program, and I have insufficient financial resources to pay for the prescribed product. I understand and acknowledge that this assistance is temporary and that this program may be changed or discontinued at any time without s Signature: Date: If Patient has a legal guardian, please complete this section:Representatives Name: Representatives Signature: Date: Describe relationship to Applicant.

7 Healthcare Professional Signature is Required to Process Application for the Sunovion Support Prescription Assistance ProgramMy signature below certifies that the person named in this form is my patient and medication received from the Program is only for that patient s use as indicated by the US Food and Drug Administration, and the information provided, to my knowledge, is accurate. I understand this Program is only for UTIBRON NEOHALER and it will not be offered for sale, trade, or barter. I agree that I will not submit any claim for reimbursement concerning the Product to Medicare, Medicaid, or any other third party, or return such Product for credit. I also agree that the Program has the right at any time to contact my patient, to modify or terminate the Program, and to recall or discontinue Product without notice.

8 To the best of my knowledge, my patient does not have prescription drug insurance coverage (including Medicare, Medicaid, county funded, or other public programs ) for the product being Professional Name: Street Address:City: State: Zip: Phone: ( ) Healthcare Professional Signature: Date: Sunovion Support Prescription Assistance Program 2017 Sunovion Pharmaceuticals Box 220285 | Charlotte, NC 28222-0285 | Phone (877) 850-0819 | Fax (877) 850-08214 Sunovion Support PRESCRIPTION ASSISTANCE PROGRAMI ndicationUTIBRON NEOHALER (indacaterol and glycopyrrolate) is a combination of a long-acting beta2-agonist, or LABA, medicine (indacaterol) and an anticholinergic medicine (glycopyrrolate).

9 UTIBRON NEOHALER is used long term, twice each day (morning and evening), to treat the symptoms of chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or Safety Information UTIBRON NEOHALER has been approved for COPD only and is NOT indicated for the treatment of asthma. People with asthma who take long-acting beta2-adrenergic agonist (LABA) medicines, such as indacaterol (one of the medicines in UTIBRON NEOHALER), have an increased risk of death from asthma problems. It is not known if LABA medicines, such as indacaterol, increase the risk of death in people with COPD. UTIBRON NEOHALER does not relieve sudden symptoms of COPD and should not be used more than twice daily.

10 Always have a short-acting beta2-agonist with you to treat sudden symptoms. Use UTIBRON NEOHALER exactly as your health care provider tells you to use it. Do not use UTIBRON NEOHALER more often than it is prescribed for emergency medical care if your breathing problems worsen quickly, you need to use your rescue medication more often than usual, or your rescue medication does not work as well to relieve your not use UTIBRON NEOHALER if you are allergic to indacaterol, glycopyrrolate, or any of the ingredients in UTIBRON NEOHALER. Ask your health care provider if you are not your health care provider about all of your health conditions, including if you: have heart problems have high blood pressure have seizures have thyroid problems have diabetes have liver problems have kidney problems have eye problems such as glaucoma have prostate or bladder problems, or problems passing urine have any other medical conditions are pregnant or plan to become pregnant are breastfeeding or plan to breastfeed are allergic to UTIBRON NEOHALER or any of its ingredients, any other medicines, or food products.