AMYLIN PATIENT ASSISTANCE PROGRAM PO BOX 42886 • CINCINNATI, OH 45242 PHONE: 1-800-330-7647 • FAX: 1-800-330-7718 [email protected]

INSTRUCTIONS FOR COMPLETING THE AMYLIN PATIENT ASSISTANCE PROGRAM APPLICATION Please review carefully: If you provide incorrect or incomplete information, it will delay the review of your application. Before mailing or faxing your application, be sure that you have completed the following information.

Please note that the Patient Assistance Application can also be completed online at www.AMYLINreimbursement.com. Patients can also track the status of the application online after submitting. PROGRAM CHECKLIST

SIGN AND DATE THE APPLICATION

COMPLETE THE APPLICATION IN ITS ENTIRETY, INCLUDING:

All insurance information (if applicable), including Medicare and Medicaid

Policy Name, ID Number, and Telephone Number for Health Plan

Prescribing Physician’s Name, Address, and Telephone Number

Required Residency Information (see below for acceptable documentation) Household Income and Household Size

PROVIDE CORRECT DOCUMENTATION OF INCOME AND RESIDENCY:

Non US citizens must include a copy of Permanent Resident Card, or Employment Authorization Document. If you are unable to provide any of these documents, please provide copies of your Social Security Card and Marriage Certi cate, or contact us at 1-800-330-7647 before submitting your application. Financial documentation is required for each household member that contributes to the household income.

If you do le taxes please submit your most recent 1040.

If you do not le taxes please submit a detailed statement of your annual household income. Please note that if you receive Social Security bene ts, IRA distributions, disabilities, pension and annuities please include as part of your household income and provide supporting documents. You must also submit W-2 forms for each member of the household, if applicable.

PROVIDE A COPY OF YOUR PRESCRIPTION (DO NOT SEND ORIGINAL)

PROGRAM ELIGIBILITY

Patient cannot have any private coverage, Medicare Part D, Medicaid, or any other form of prescription coverage Patient must be a US Citizen or Legal Resident Patient’s total household income must be at or below 200% of the Federal Poverty Level*: Household Size: 1 - $22,340 4 - $46,100 7 - $69,860

2 - $30,260 5 - $54,020 8 - $77,780 3 - $38,180 6 - $61,940 9 or more - add $7,920 for each additional person *Please call the Amylin Reimbursement Hotline for more information on the guidelines for Alaska and Hawaii

Disclaimer: The criteria for the Amylin Patient Assistance Program is subject to change without notice at the discretion of the manufacturer. 00-10-10265-C ©2012 Amylin Pharmaceuticals, Inc. All rights reserved. AMYLIN PATIENT ASSISTANCE PROGRAM PATIENT ASSISTANCE APPLICATION PO BOX 42886 • CINCINNATI, OH 45242 PHONE: 1-800-330-7647 • FAX: 1-800-330-7718 This form can be completed online [email protected] at www.AMYLINreimbursement.com

HEALTHCARE PROVIDER INFORMATION Physician Name ______Address ______City ______State ______Zip Code ______Email ______Telephone ______Fax ______Office Contact ______

PRESCRIPTION INFORMATION Please check one: BYETTA® BYDUREON™ SymlinPen® (exenatide) injection (exenatide extended-release for injectable suspension) (pramlintide acetate) pen-injector PATIENT INFORMATION Patient First Name ______MI ______Patient Last Name ______Mailing Address ______City ______State ______Zip Code ______

Phone ______Date Of Birth (MM/DD/YYYY) ______Social Security #______Email Address ______Are you a U.S. citizen or permanent resident? Yes No Pharmacy Name ______Pharmacy Phone ______Pharmacy Fax ______Are you employed? No Yes If Yes, check your employment type: Full Time Part Time Self-employed Employer Name ______Address ______Household Size (number of persons dependent upon total household income) ______Annual Household Income ______

Do you take insulin for control of your diabetes? Yes No Which type of diabetes do you have? Type 1 Type 2

INSURANCE INFORMATION Are you a participant in any of the following? (Check all that apply): Medicare Part A Yes No TriCare/CHAMPUS Yes No Medicare Part B Yes No Veterans Administration Yes No Medicare Part C (Medicare Advantage) Yes No Indian Health Services Yes No Medicare Part D (Medicare prescription drug plan) Yes No Public Health Service Yes No Medicaid Yes No Any other Federal or State Healthcare Program If yes, please list______Do you have private health insurance? Yes No If yes, name of Primary Insurer ______ID ______Phone ______Name of Secondary Insurer ______ID ______Phone ______Have you applied for Medicaid? Yes No

If yes, date you applied ______Were you approved? Yes No PATIENT CERTIFICATION, DISCLAIMER, AND WAIVER By signing below I attest and verify that all insurance and income information provided on this application, as well as all supporting documentation I have provided, is complete and accurate. I consent to have Amylin or its agents audit or otherwise verify the information I have provided to determine my eligibility for the Patient Assistance Program (PAP). I consent to the release of my confidential information, including the information on this form, both to my physician from a Reimbursement Specialist and by my physician for the purposes of determining eligibility under the PAP. I authorize the assigned Reimbursement Specialist to contact the insurance companies listed on this form as well as other potential city, state, county or federal funding sources, social worker, or patient advocacy organization to determine my eligibility for alternate health insurance coverage/funding. Patient Name ______Signature ______Date _____ /______/ ______Parent or Guardian Signature (if applicant is under 18) ______Relationship: ______Date _____ /______/ ______

Disclaimer: The criteria for the Amylin Patient Assistance Program are subject to change without notice at the discretion of the manufacturer. For important safety information about the risk of severe low blood sugar, please read the Important Patient Safety Information and the SYMLIN Medication Guide at www.SYMLIN.com.

For important information regarding the risk of thyroid C-cell tumors, please read the BYDUREON Prescribing Information and Medication Guide.

00-10-10261-C ©2011 Amylin Pharmaceuticals, Inc. All rights reserved. The SymlinPen mark and BYETTA mark are registered trademarks of Amylin Pharmaceuticals, Inc. BYDUREON is a trademark of Amylin Pharmaceuticals, Inc.