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BOTOX® Financial Assistance Guide ~

CHAMP has created the financial assistance guide below for anyone who has been prescribed BOTOX® by their healthcare provider. BOTOX® is a prescription medicine that is injected to prevent headaches for those living with chronic migraine disease. If you or someone you know requires help with paying for treatment, please review the details provided below to see if you qualify for the manufacturer's financial assistance program and how best to access BOTOX®.

Please note: This guide has not been produced or approved by the manufacturer of BOTOX®. CHAMP does not endorse the use of any treatment over another, nor promote the use of this treatment for everyone living with migraine disease. Please consult your healthcare providers to determine if BOTOX® is right for you.

BOTOX® is covered by most insurers, but numerous patients still have out-of-pocket costs. If you are prescribed BOTOX®, Allergan is offering financial assistance programs to help cover the costs. Each program is different and various programs exist to support patients with private or public insurance, as well as the uninsured.

To help patients understand this program, the Coalition For Headache And Migraine Patients (CHAMP) has created a Financial Assistance Guide. This guide has not been produced or approved by the medication manufacturer. CHAMP is not endorsing the use of any treatment over another, nor promoting the use of this treatment for everyone with migraine disease. Every patient needs to consult their healthcare provider to determine what treatment is right for you.

I have been prescribed BOTOX®. What financial assistance programs exist to help me?

I Have a Private/Commercial Insurance Plan

This category includes insurance plans provided through an employer, purchased with subsidy support from the Affordable Care Act

(Obamacare) or purchased privately.

Highlights of the BOTOX® Savings Program

Most insurance plans cover the majority of BOTOX® costs and on average, you will pay $164 out of pocket per treatment*. Depending on your

insurance coverage, eligible insured patients can receive reimbursement to help with remaining costs allowing you to pay $0. The BOTOX® Savings Program covers out-of-pocket costs up to $700 per treatment for up to 5 treatments over a 12-month period. The yearly maximum savings limit is $3500 over a 12-month period. Please note that the BOTOX® Savings Program covers the cost of the product and out-of-pocket costs for the

injection but does not cover any associated office visit costs.

*Average cost per treatment based on al/erganpricing.com.

Information on the BOTOX® Savings Program on the following page

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STEP 1 - Your doctor writes you a prescription for BOTOX®.

STEP 2 - Visit botoxsavingsprogram.com to check eligibility and enroll in the program. You may be eligible if you’re 18 years or older, have commercial insurance and receive BOTOX® treatment for chronic migraine. BOTOX® is NOT approved for the treatment of episodic migraine disease.

STEP 3 - Once you are enrolled and after you receive your first treatment, you will receive an Explanation of Benefits (EOB) from your insurance plan.

STEP 4 - Visit botoxsavingsprogram.com to complete the online claim submission form. You must attach a scanned in copy of your EOB. Click submit.

STEP 6 - If your claim is accepted and processed, you will receive a BOTOX® Savings Program reimbursement check in as little as 2-3 weeks.

STEP 5 - If your claim is rejected, please contact 1-800-44-BOTOX®

Steps to Benefit from the BOTOX® Savings Program

I Have Medicare,

Medicaid or other

Government Insurance

Plan

Currently, Allergan does not have a financial assistance program for patients whose medical insurance is provided by state or federal programs, like Medicare and Medicaid.

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Call the hotline at 1-800-44-BOTOX® (1-800-442-6869). A Reimbursement Counselor can help answer questions and send you an application. Or partner with your healthcare provider to complete a Program Application online at www.botoxone.com/PatientAssistanceProgram.

Submit the completed application and supporting documents.

Once received and reviewed, we will send a Notification Letter and Product Request Form so you may begin your BOTOX® treatment.

To apply, follow the simple steps below

I Am Uninsured

The BOTOX® Savings Program is not available to those patients who are uninsured or underinsured.

You may be eligible to receive BOTOX® at no cost from the Allergan Patient Assistance Program if you meet the following requirements:

You are uninsured or underinsured

You are a resident of the United States or Puerto Rico

You have income less than or equal to 500% of the Federal Poverty Level

If you have this many people in your household…

…your household income must be equal to or below this much each year

1 $62,450

2 $84,550

3 $106,650

4 $128,750

5 $150,850

6 $172,950

7 $195,050

8 $217,150

Each additional person Add $4,420

This table does not include Hawaii or Alaska which have slightly adjusted FPL. Please visit aspe.hhs.gov/2019-poverty-guidelines for more info

About CHAMP

CHAMP provides support to people with headache, migraine and cluster diseases who are often stigmatized and under-served. CHAMP brings together organizations and leaders in this disease area to enhance communication , coordination and collaboration. CHAMP also organizes patient advocates to fight stigma and achieve fair access to treatments. If you would like to be a patient advocate for people living with headache diseases, sign up at the CHAMP website: HeadacheMigraine.org.

Where do I turn if I am not eligible for a financial assistance program?

Brand Name

Biologic Name

Pharmaceutical Company

Administration

Indication

Full Prescribing Information

Website

Helpline

Administration Training Available

Horne Delivery Available

The Patient Advocate Foundation (a CHAMP member organization)

PAf Patient Advocate can be a helpful resource for patients and caregivers who are J~, Foundation experiencing access challenges. PAF provides a suite of expert tips

to help navigate insurance denials, appeals and common barriers at: patientadvocate.org/migrainematters.

PAF also offers one-on-one case management assistance through its dedicated Migraine Careline for people living with migraine who experience access challenges. The Migraine Careline provides assistance with navigating eligibility and enrollment in disability benefits and overcoming insurance coverage and financial burdens that impact patient access to care.

All services are completely free and provided through phone and/or email communication. Visit https://migraine.pafcareline.org or call 866-688-3625 to speak with a case manager today.

BOTOX® Basics

BOTOX"'

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Allergan

Treatment session by injection in your doctor's office every 12 weeks

Adults living with chronic migraine disease (15 or more headache days per month, each lasting 4 hours or more)

BOTOX® is NOT approved for adults living with episodic migraine disease (14 or fewer headache days per month).

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Call 1-800-44-BOTOX® to speak to a BOTOX® Savings Program Customer Service Manager, Monday-Friday, 8 arn-8 pm ET or visit BOTOXChronicMigraine.corn for educational support and more.

No, BOTOX® must be administered by a trained healthcare provider.

No, your prescription is sent to your healthcare provider.