The EOHILIA Patient Support and Copay Program

Eligible patients may pay as little as $0 if EOHILIA™ (budesonide oral suspension) is covered by their commercial insurance, with a max annual benefit of up to $2500 off their copay or out-of-pocket expenses. A valid Prescriber ID# is required on the prescription. Offer not valid for cash paying patients. You must be 18 years or older to use the EOHILIA™ Copay Offer for yourself or a minor.

Commercially insured patients prescribed EOHILIA™ may receive a one-time 30-day supply at no cost if access is not initially granted by the payer. Takeda may notify the patient’s payer that the patient is receiving a free supply of medicine. The free supply may not be sold, purchased or traded, or offered for sale.

Patient Instructions: Follow the dosage instructions given by the doctor. This offer may not be redeemed for cash. By using this offer, you are certifying that you meet the eligibility criteria and will comply with the terms and conditions described in the Terms and Conditions section below and understand and acknowledge the Takeda Privacy Notice (www.takeda.com/privacy-notice). Patients with questions about the EOHILIA™ Copay Offer should call 1-866-861-1482.

Pharmacist Instructions: When you apply this offer, you certify that: (1) you have not submitted and will not submit a claim for reimbursement for the portion of the prescription covered by this offer to any payer; (2) your participation in this program is consistent with all applicable laws and any obligations, contractual or otherwise, that you may have as a pharmacy provider; (3) By participating in this program, you are certifying that you will comply with the terms and conditions described.

Pharmacist Instructions For A Patient With An Eligible Third Party: Submit the claim to the primary Third Party Payer first, then submit the balance due to CHANGE HEALTHCARE as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code, (e.g. 8). The patient pay amount submitted will be reduced by up to $1800 and reimbursement will be received from CHANGE HEALTHCARE. Valid Other Coverage Code required. For any questions regarding Change Healthcare online processing, please call the Help Desk at 1-800-433-4893.

Terms and Conditions: The Eohilia™ Copay Offer (“Offer”) provides financial support for commercially insured patients who qualify for the Offer. By using this Offer, the patient certifies that the program is intended solely for his or her benefit—not health plans and/or their partners. This Offer cannot be used if patient is a beneficiary of, or any part of the prescription is covered by: (1) any federal, state, or government-funded healthcare program (Medicare, Medicare Advantage, Medicaid, TRICARE, etc.), including a state pharmaceutical assistance program (the Federal Employees Health Benefit (FEHB) Program is not a government-funded healthcare program for the purpose of this Offer), (2) the Medicare Prescription Drug Program (Part D), or if patient is currently in the coverage gap, or (3) insurance that is paying the entire cost of the prescription. Patient may not seek reimbursement from any other plan or program (Flexible Spending Account [FSA], Health Savings Account [HSA], Health Reimbursement Account [HRA], etc.) for any out-of-pocket costs covered by this Offer. Cash Discount Cards and other non-insurance plans are not valid as primary under this Offer. This does not constitute health insurance. By using this Offer, the patient certifies that he or she will comply with any terms of his or her health insurance contract requiring notification to his or her payer of the existence and/or value of this Offer. It is illegal to (or offer to) sell, purchase, or trade this Offer. This Offer is not transferable and is limited to one Offer per person and may not be combined with any other coupon, discount, prescription savings card, rebate, free trial, patient assistance, co-pay maximizer, alternative funding program, co-pay accumulator, or other offer, including those from third parties and companies that help insurers or health plan manage costs. This Offer is valid in the United States, including Puerto Rico and other U.S. territories. This Offer is not valid if reproduced. Void where prohibited by: your insurance provider, law, taxed, or restricted. By utilizing this Offer, you hereby accept and agree to abide by these terms and conditions. Any individual or entity who enrolls or assists in the enrollment of a patient in this Offer represents that the patient meets the eligibility criteria and other requirements described herein. You must meet the program eligibility requirements every time you use the program. Program managed by ConnectiveRx on behalf of Takeda Pharmaceuticals U.S.A., Inc. The parties reserve the right to rescind, revoke, or amend this Offer without notice at any time.