Full Prescribing Information, including Boxed Warning

By accepting the offer, I confirm that I do not have Medicare, Medicaid, or other public payer coverage and I am eligible for this offer in accordance with the Terms and Conditions.

1. Download the digital savings card and present it at your pharmacy
2. Ask your pharmacist to fill your existing prescription with Teva’s Lapatinib Tablets

Terms, Conditions, and Eligibility Requirements: Eligible patients must have commercial prescription insurance with coverage for Teva’s Lapatinib Tablets. Uninsured and cash-paying patients are NOT eligible for this Program. Patients enrolled in any state or federally funded healthcare program, including but not limited to, Medicare, Medigap, Medicaid, VA, DOD, TRICARE, Puerto Rico Government Health Insurance Plan, Medicare-eligible patients enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees, are NOT eligible for this Program. Cash Discount Cards and other noninsurance plans are not valid as primary under this Program. This Program is restricted to residents of the United States and United States territories.

Patients may pay as little as $15 out of pocket for Teva’s Lapatinib Tablets. Maximum Program assistance per prescription and annual benefits apply and out-of-pocket expenses may vary. Patient is responsible for costs above maximum benefit amounts. This Program is not insurance. Void if copied, transferred, purchased, altered, or traded and where prohibited and restricted by law. The Program is not transferable. No substitutions are permitted. The Program form may not be sold, purchased, traded, or counterfeited. Void if reproduced. The Program benefit cannot be combined with any other financial assistance program, free trial, discount, prescription savings card, or other offer. This Program is managed by TrialCard on behalf of Teva Pharmaceuticals USA, Inc. Teva Pharmaceuticals USA, Inc. and its affiliates reserves the right to make eligibility determinations, to set Program benefit maximums, to monitor participation, and to change, rescind, revoke, or discontinue this Program at any time without notice. Limit one Program enrollment per individual. If you have any questions regarding this Program, your eligibility or benefits, or if you wish to discontinue your participation, please call 844-248-7949. Expiration Date: 12/31/2025.

Valid only for Teva’s Lapatinib Tablets, National Drug Code: 00480-3237-51

To the Patient: By redeeming this Program, you acknowledge that you are an Eligible Patient and you understand and agree to comply with the terms and conditions of this Program.

This Program is for eligible Commercially Insured Patients only. Patients may pay as little as $15 out of pocket for Teva’s Lapatinib Tablets. Maximum Program assistance per prescription and annual benefits apply and out-of-pocket expenses may vary. This Program must be presented along with your prescription for Lapatinib Tablets and your primary insurance card to participate in this Program. Program not valid for Non-Insured/Cash-Paying Patients or where Teva’s Lapatinib Tablets are not covered by the primary insurance.

To the Pharmacist: When you apply this Program, you are certifying that Teva’s Lapatinib Tablets are being dispensed to an Eligible Patient 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 Commercially Insured Patients, please submit this claim to the primary Third-Party Payer first, then submit the balance due to TrialCard as a Secondary Payer COB (coordination of benefits) with patient responsibility and a valid Other Coverage Code (e.g., 08).

Reimbursement will be received from TrialCard. For questions regarding processing, please call the Help Desk at 844-248-7949.

© 2023 Teva Pharmaceuticals USA, Inc. TG-43439 August 2023
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