PROGRAM RESOURCES AND FORMS

OZURDEX Program Terms and Conditions

1. This offer is valid only for patients 18 years of age or older who have commercial insurance coverage for OZURDEX^® (dexamethasone intravitreal implant). 2. This offer is not valid for use by patients enrolled in Medicare, Medicaid, or other federal or state programs (including any state pharmaceutical assistance programs), or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this offer if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. This offer is not valid for cash-paying patients. 3. Depending on insurance coverage, most eligible insured patients may pay as little as $0 for each eye, up to one (1) OZURDEX implant per eye. This offer applies to the implant only and does not apply to costs for any other medication, procedure, or diagnostic service. Check with healthcare provider and insurance plan for discount. Maximum reimbursement limit of $5,000.00 per patient applies; patient out-of-pocket expense will vary. 4. Claims must be submitted within 365 days of the treatment date and must include a copy of (a) an Explanation of Benefits (EOB) for OZURDEX, (b) OZURDEX Reimbursement Request Form, and (c) documentation from the physician’s office indicating the product code, the patient-paid amount, and the diagnosis of an FDA-approved indication. 5. Patients and healthcare providers may not seek reimbursement for value received from the OZURDEX Savings Program from any third-party payers. 6. AbbVie reserves the right to rescind, revoke, or amend this offer without notice. 7. Offer good only in the USA, including Puerto Rico and Guam. Patients residing in or receiving treatment in certain states may not be eligible to participate in this program. 8. Void if prohibited by law, taxed, or restricted. 9. This offer is not transferable. The selling, purchasing, trading, or counterfeiting of this offer is prohibited by law. 10. This offer has no cash value and may not be used in combination with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription. 11. This offer is not health insurance. 12. By redeeming this offer, patient represents they meet the eligibility criteria above and patient understands and agrees to comply with the terms and conditions of this offer. 13. To learn about AbbVie’s privacy practices and your privacy choices, visit https://abbv.ie/corpprivacy.

For questions about this program, please call 1-866-OZURDEX (1-866-698-7339).

Pharmacist Instructions for a Patient with an Eligible Third-Party Payer: When you redeem this card, you certify that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government programs for this prescription. Submit the claim to the primary third-party payer first, then submit the balance due to IQVIA (OPUS) using BIN #601341 as a Secondary Payer COB (coordination of benefits) with patient responsibility amount and a valid Other Coverage Code (8). The patient's out-of-pocket expense will be reduced up to the maximum reimbursement limit for the program. Reimbursement will be received from IQVIA. For any questions regarding online processing, call the Help Desk at 1-800-364-4767.

Program managed by IQVIA Inc. on behalf of AbbVie.