TERMS AND CONDITIONS

AMRIX Savings Program Terms and Conditions

Commercially insured patients pay as little as $15 on each fill. Maximum benefit and quantity limits apply, minimum 14 capsules per fill. Limit 2 uses per month.

Patients are not eligible if prescriptions are paid for in part or full by any state or federally funded programs, including but not limited to Medicare, Medicaid, Medigap, VA, DOD, TRICARE, or by private health benefit programs which reimburse for the entire cost of prescription drugs. This card is not valid for patients who are Medicare eligible and are enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees (i.e., patients who are eligible for Medicare Part D but receive a prescription drug benefit through a former employer). Cash Discount Cards and other non-insurance plans are not valid as primary under this offer. If the patient is eligible for drug benefits under any such program, the patient cannot use this offer. By redeeming 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 payor of the existence and/or value of this offer and that the patient is eligible for, and will comply with, the terms of this offer. By redeeming this offer, the patient and the pharmacist acknowledge that the patient is eligible, and the patient and pharmacist understand and agree to comply with the Terms and Conditions of this offer. Offer not valid for patients under 18 years of age.

Void if copied, transferred, purchased, altered or traded and where prohibited and restricted by law. This is not an insurance program. Valid only in the United States including the Commonwealth of Puerto Rico. Void in the Commonwealth of Massachusetts and the State of California, and where otherwise prohibited by law. This offer may not be used with any other discount, coupon or offer. This offer expires on December 31, 2019. This program is managed by ConnectiveRx on behalf of Teva Pharmaceuticals USA, Inc.. Teva reserves the right to limit, change or discontinue this offer at any time without notice. If you have any questions regarding your eligibility or benefits, please call 1-833-378-7361.

To the Commercially-insured Patient: In order to redeem this offer you must have a valid prescription for AMRIX. Follow the dosage instructions given by the doctor. This offer must be presented along with your prescription for AMRIX and your primary insurance card. Patients with questions about the AMRIX Savings Offer should call 1-833-378-7361.

To the Pharmacist: By redeeming this offer, the Pharmacist certifies that AMRIX is being dispensed to a patient eligible for this offer in compliance with these Terms and Conditions and the pharmacy has not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental program for this prescription. For any questions regarding CHANGE HEALTHCARE online processing, please call the Help Desk at 1-800-422-5604. Pharmacist Instructions for Commercially Insured Patients: Please 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). Reimbursement will be received from CHANGE HEALTHCARE. 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 AMRIX prescriptions.

What is AMRIX?

AMRIX ® (cyclobenzaprine hydrochloride extended-release capsules) is a prescription medicine used along with rest and physical therapy to help treat muscle spasm due to acute, painful musculoskeletal problems. AMRIX should only be used for up to 2 or 3 weeks. It is not known if AMRIX is effective when used for longer periods. It is not known if AMRIX is safe and effective in children.

IMPORTANT SAFETY INFORMATION

Who should not take AMRIX?

Do not take AMRIX if you:

Talk to your healthcare provider before taking this medicine if you have any of the conditions listed above.

What should I avoid while taking AMRIX?

You should not drink alcohol until you know how AMRIX affects you. Taking AMRIX with alcohol or other medicines that depress your central nervous system can slow your thinking and physical response times.

Do not drive, operate machinery, or do other dangerous activities until you know how AMRIX affects you.

What are possible side effects of AMRIX?

AMRIX may cause serious side effects that may lead to heart attack or stroke. Call your healthcare provider immediately or go to the nearest hospital emergency room if you have:

Serotonin syndrome is a serious medical condition that may happen when AMRIX is taken with certain other medicines. Call your healthcare provider right away or go to the nearest hospital emergency room if you become severely ill and have some or all of these symptoms:

The most common side effects of AMRIX include dry mouth, dizziness, fatigue, constipation, nausea, upset stomach, and drowsiness.

Tell your healthcare provider if you get any side effect that bothers you or that does not go away. These are not all the possible side effects of AMRIX. For more information, talk to your healthcare provider or pharmacist.

Please see the Patient Information Leaflet within the Full Prescribing Information.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088