Gilead Advancing Access® Co-pay Savings Card Activation

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Eligibility

Are you (the requestor) 18 years of age or older?* You must be 18 years of age or older to enroll for yourself or on behalf of a minor. For more information about your eligibility for this or other programs, please call 1-800-226-2056.

Yes No

Are you a current resident of the United States, Puerto Rico, or US territories?* The Gilead Advancing Access® Co-pay Savings Program is available only to residents of the United States, US Territories, or the Commonwealth of Puerto Rico. For more information about your eligibility for this or other programs, please call 1-800-226-2056.

Yes No

Are your prescriptions paid for in part or in full by any state or federally funded program, including but not limited to Medicare or Medicaid, VA, DOD, or TRICARE?* The Co-pay Savings Program is available only to people who currently do not participate in state or federally funded programs. For more information about your eligibility for this or other programs, please call 1-800-226-2056.

Yes No

If you begin receiving prescription benefits from such state, federal, or government-funded program at any time, you will no longer be eligible to use the Gilead Advancing Access® Co-pay Savings Program.

Do you acknowledge your agreement with this statement? In order to be eligible for the Co-pay Savings Program, you must agree with this statement. If you would like to discuss further, please call 1-800-226-2056.

Yes No

Do you understand and agree to the Co-pay Savings Program terms and conditions including the limitations regarding accumulator adjustment and co-pay maximizer programs?* In order to be eligible for the Co-pay Savings Program, you must agree with this statement. If you would like to discuss further, please call 1-800-226-2056.

Yes No

*Indicates a required field

I understand that Gilead and third parties working on Gilead’s behalf will obtain, review, use, and disclose my information in connection with my participation in the Co-pay Savings Program. The information I provide may be used to determine my eligibility, process claims, assess for additional programs that may be helpful to me, communicating with me as necessary to administer the program, ensure efficient operation of the program, make improvements to the program and for fraud prevention and compliance purposes. Additionally, I understand that Gilead may use the information I provide to obtain my insurance information from third parties. Additional information can be found at Gilead’s Privacy Statement and Consumer Health Data Privacy Policy. (REQUIRED)

Eligibility

Are you (the requestor) 18 years of age or older?* You (the requestor) must be 18 years of age or older to enroll in the program.

Yes No

Is the individual a current resident of the United States, Puerto Rico, or US territories?* The Gilead Advancing Access® Co-pay Savings Program is available only to residents of the United States, US Territories, or the Commonwealth of Puerto Rico. For more information about your eligibility for this or other programs, please call 1-800-226-2056.

Yes No

Are the individual’s prescriptions paid for in part or in full by any state or federally funded program, including but not limited to Medicare or Medicaid, VA, DOD, or TRICARE?* The Co-pay Savings Program is available only to people who currently do not participate in state or federally funded programs. For more information about your eligibility for this or other programs, please call 1-800-226-2056.

Yes No

If the individual begins receiving prescription benefits from such state, federal, or government-funded program at any time, they will no longer be eligible to use the Gilead Advancing Access® Co-pay Savings Program.

Does the individual acknowledge and agree with this statement?* In order to be eligible for the Co-pay Savings Program, you must agree with this statement. If you would like to discuss further, please call 1-800-226-2056.

Yes No

Does the individual understand and agree to the Co-pay Savings Program terms and conditions including the limitations regarding accumulator adjustment and co-pay maximizer programs?* In order to be eligible for the Co-pay Savings Program, you must agree with this statement. If you would like to discuss further, please call 1-800-226-2056.

Yes No

*Indicates a required field

I certify that I am an authorized representative under federal and state law to enroll in the Gilead Advancing Access Co-pay Savings program on behalf of the individual. The individual understands that Gilead and third parties working on Gilead’s behalf will obtain, review, use, and disclose their information in connection with their participation in the co-pay savings program. The information provided may be used to determine their eligibility, process claims, assess for additional programs that may be helpful to the individual, communicate as necessary to administer the program, ensure efficient operation of the program, make improvements to the program and for fraud prevention and compliance purposes. Additionally, the individual understand that Gilead may use the information provided to obtain the individual insurance information from third parties. Additional information can be found at Gilead’s Privacy Statement and Consumer Health Data Privacy Policy. (REQUIRED)

First name:

Last name:

Date of birth (MM/DD/YYYY):

I am an authorized representative signing up on behalf of the patient, who is under 18.

Address 1:

Address 2:

City:

State:

ZIP code:

Email:

Phone number:

Indicates a required field

Which of the following medications are you currently taking? BIKTARVY® (bictegravir/ emtricitabine/ tenofovir alafenamide) COMPLERA® (emtricitabine/ rilpivirine/ tenofovir disoproxil fumarate) DESCOVY® (emtricitabine/ tenofovir alafenamide)

What has your doctor prescribed DESCOVY for? To treat HIV-1 To reduce the risk of getting HIV-1

EMTRIVA® (emtricitabine) GENVOYA® (elvitegravir/ cobicistat/ emtricitabine/ tenofovir alafenamide) ODEFSEY® (emtricitabine/ rilpivirine/ tenofovir alafenamide) STRIBILD® (elvitegravir/ cobicistat/ emtricitabine/ tenofovir disoproxil fumarate) TRUVADA® (emtricitabine/ tenofovir disoproxil fumarate)

What has your doctor prescribed TRUVADA for? To treat HIV-1 To reduce the risk of getting HIV-1

TYBOST® (cobicistat)

Indicates a required field

Disclaimer: In certain states, the law restricts patient co-pay coupon assistance for TRUVADA.

Marketing communications opt-in (OPTIONAL)

I would like to receive marketing and informational communications from Gilead Sciences, Inc. and third parties working on behalf of Gilead related to my medical condition, treatment, and/or my prescription medication, including offers, marketing and promotional information, educational materials, financial assistance, including the customer relationship marketing program via one or more of the communications methods I agreed to above. I understand that opting into the marketing and informational communications is not required as a condition of (i) eligibility for health plan benefits or ability to obtain treatment from my healthcare providers, (ii) purchasing any goods or receiving a co-pay or other support from Gilead. The marketing outreach program is separate from the Co-pay Savings Program. I understand that I may stop receiving communications at any time by calling 1-800-226-2056 or clicking on the "unsubscribe" link at the bottom of the emails I receive from Gilead. (NOTE: Gilead Advancing Access may communicate with me as necessary to administer the Program, even if I do not opt in to receive marketing and informational communications from Gilead.)

By checking this box, I consent to receive marketing and informational communications from Gilead (as described above) to my phone number provided, including text messages, prerecorded messages and phone calls, which may be sent via autodialer. Text and data rates may apply. I may opt out at any time by texting “STOP.”

Thank you

Your Gilead Advancing Access® Co-pay Savings card is now activated.

Present your card to your pharmacist to save on your next prescription.

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Please call 1-800-226-2056 to speak to a customer service representative.

Co-pay Savings Program Benefits

Subject to the Gilead Advancing Access® Co-pay Coupon (“Savings Program”) Terms and Conditions, this program provides the following financial assistance for the out-of-pocket costs for eligible commercially insured patients with a valid prescription:
- Up to $8,000 in cost-sharing assistance per calendar year including up to $100 per visit for injection administration with no monthly limit for the following product:
  - YEZTUGO® (lenacapavir)
- Up to $9,600 in cost-sharing assistance per calendar year with no monthly limit for the following product:
  - SUNLENCA® (lenacapavir)
- Up to $7,200 in cost-sharing assistance per calendar year with no monthly limit for the following products:
  - BIKTARVY® (bictegravir/emtricitabine/tenofovir alafenamide)
  - DESCOVY® (emtricitabine/tenofovir alafenamide)
  - GENVOYA® (elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide)
  - TRUVADA® (emtricitabine/tenofovir disoproxil fumarate)
- Up to $6,000 in cost-sharing assistance per calendar year with no monthly limit for the following products:
  - ODEFSEY® (emtricitabine/rilpivirine/tenofovir alafenamide)
  - STRIBILD® (elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate)
  - COMPLERA® (emtricitabine/rilpivirine/tenofovir disoproxil fumarate)
- Up to $3,600 in cost-sharing assistance per calendar year, with a monthly maximum of $300 in cost-sharing assistance, for the following product:
  - EMTRIVA® (emtricitabine)
- Up to $600 in cost-sharing assistance per calendar year, with a monthly maximum of $50 in cost-sharing assistance, for the following product:
  - TYBOST® (cobicistat)
As described in the Savings Program Terms and Conditions, Gilead may reduce or discontinue the financial assistance available under the Savings Program if it determines the patient is subject to an “accumulator adjustment” or “co-pay maximizer” program.
- If Gilead determines that a patient’s insurer (or its agent) has implemented a program that adjusts patient cost-sharing obligations based on the availability of support under the Savings Program (sometimes called a “co-pay maximizer program”), unless prohibited by law, Gilead may discontinue the cost-sharing assistance available under the Savings Program after providing assistance in an amount not to exceed the lesser of the Affordable Care Act (ACA) out-of-pocket maximum or current Savings Program limit.
- If Gilead determines that a patient’s insurer (or its agent) has implemented a program that excludes the financial assistance provided under the Savings Program from counting towards the patient’s deductible or out-of-pocket cost limitations (sometimes called an “accumulator adjustment program”), unless prohibited by law, Gilead may reduce the cost-sharing assistance available under the Savings Program to a per claim maximum of $25. Please contact Advancing Access^® at 1-800-226-2056 to determine if additional cost-sharing assistance is available.
These Savings Program benefits are subject to change for any reason at any time without notice.

Gilead Advancing Access® Co-pay Savings Program Terms and Conditions:

The Gilead Advancing Access® Co-pay Savings Program (“Savings Program”) provides financial assistance for the out-of-pocket costs for eligible commercially insured patients as described in the Savings Program Benefits above. Savings Program benefits are limited to financial assistance for patient cost-sharing for the applicable Gilead product and product administration (administration financial assistance only available for certain products).
The Savings Program can be used only by eligible residents of the US, Puerto Rico, or US territories at participating eligible pharmacies in the US, Puerto Rico, or US territories. Product must be dispensed in the US, Puerto Rico, or US territories. Individuals must be at least 18 years old to use the Savings Program themselves or to enroll in the Savings Program on behalf of a minor.
To use the Savings Program, the patient (or the authorized representative under federal or state law enrolling on behalf of the patient, as applicable) must personally complete the enrollment process for the Savings Program. Third-party payers, pharmacy benefit managers, or the agents of either, are prohibited from assisting patients with enrolling in the Savings Program. Any decision to enroll in the Savings Program must be made voluntarily by the patient.
The Savings Program is not insurance and is not intended to substitute for insurance. Uninsured and cash-paying patients are not eligible to use the Savings Program. The Savings Program is valid only for prescriptions that are reimbursed by commercial insurance and is not valid for prescriptions that are eligible to be reimbursed:
- in whole or in part by Medicare or a Medicare Part D plan, Medicaid, TRICARE, VA, DOD, Puerto Rico Government Health Insurance Plan, or any other state or federally funded healthcare benefit program (collectively, “Government Programs”); or
- by commercial plans or other health or pharmacy benefit programs that reimburse for the entire cost of prescription drugs or prohibit the use of the savings card.
Patients who begin receiving prescription benefits from Government Programs at any time must notify Gilead of this fact by contacting Advancing Access at 1-800-226-2056 and will no longer be eligible to use the Savings Program.
The Savings Program is limited to one per person and is not transferable. No substitutions are permitted. This Savings Program is offered to, and intended for the sole benefit of, eligible patients and may not be utilized for the benefit of third parties, including, without limitation, third-party payers, pharmacy benefit managers, or the agents of either. If Gilead determines that a patient’s insurer has implemented a program that adjusts patient cost-sharing obligations based on the availability of support under the Savings Program (sometimes called a “co-pay maximizer program”), unless prohibited by law, Gilead may discontinue the cost-sharing assistance available under the Savings Program after providing assistance in an amount not to exceed the lesser of the Affordable Care Act (ACA) out-of-pocket maximum or current Savings Program limit. If Gilead determines that a patient’s insurer has implemented a program that excludes the financial assistance provided under the Savings Program from counting towards the patient’s deductible or out-of-pocket cost limitations (sometimes called an “accumulator adjustment program”), unless prohibited by law, Gilead may reduce the cost-sharing assistance available under the Savings Program to a per claim maximum of $25. Patients may contact Advancing Access^®at 1-800-226-2056 to determine if additional cost-sharing assistance is available.
The Savings Program is only available with a valid prescription. No other purchase is necessary to redeem this offer.
The Savings Program cannot be combined with any other coupon, free trial, discount, prescription savings card, or other offer (including, without limitation, any program offered by a third-party payer or pharmacy benefit manager, or an agent of either, that adjusts patient cost-sharing obligations). Patients are not eligible to use the Savings Program for a product if they are currently receiving free drug assistance through Gilead Sciences, Inc. (“Gilead”)’s patient assistance program for that product.
The Savings Program will not reimburse any payments made by Flexible Spending Account (FSA), Health Savings Account (HSA), Health Reimbursement Account (HRA), or any other payor, discount/co-pay program, or other offer.
Void where prohibited by law, taxed, or restricted.
Patient, pharmacist, and prescriber agree not to seek reimbursement for all, or any part of the benefit received by the patient through the Savings Program. Both patient and pharmacist are each individually responsible for reporting receipt of the Savings Program benefit to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the Savings Program, as may be required.
It is illegal to sell, purchase, trade, or counterfeit, or offer to sell, purchase, trade, or counterfeit the Savings Program.
Certain information pertaining to your use of the Savings Program will be shared with Gilead, the sponsor of the Savings Program, and its affiliates. The information disclosed will include the patient co-pay ID, pharmacy demographics, prescriber information, and details relating to the co-pay claim, such as co-pay amount, insurance details, and the therapy received. For more information, please see the Gilead's Privacy Statement and Consumer Health Data Privacy Policy available at www.gilead.com.
Gilead Sciences reserves the right to terminate, rescind, revoke, or modify the Savings Program for any reason at any time without notice.

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