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ZEGALOGUE^® (dasiglucagon) injection

TERMS AND CONDITIONS
Patient Instructions: The ZEGALOGUE^® (dasiglucagon) injection Co-Pay Savings Card Program is ONLY valid for patients with commercial (private) insurance. In order to redeem this offer, you must have a valid prescription for ZEGALOGUE and you may not be enrolled in a state or federally funded prescription benefit program, including, but not limited to, Medicare (Parts A, B, C, or D), Medicaid (including Managed Medicaid), Veterans Affairs (VA), Department of Defense (DOD), or TRICARE. You are responsible for the first $25 and the card pays the remainder per prescription, up to a maximum of 12 fills per calendar year. Follow instructions provided by your doctor. This offer may not be redeemed for cash. By using this offer, you are certifying that you meet the eligibility criteria and will comply with the terms and conditions described in the Restrictions section below, including that you will not seek reimbursement for any part of the benefit received through this offer from any third-party payer, including any health savings, flexible spending, or other healthcare reimbursement account. Patients with questions about the offer should call 1-877-501-ZEGA (9342). THIS OFFER IS NOT INSURANCE.

Pharmacist: As a condition of payment, when you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental programs including, without limitation, Medicare, Medicaid, VA, DOD, or TRICARE, for this prescription and will not seek reimbursement from health insurance or any third party for any part of the benefit the patient receives through this program. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. By participating in this program, you are certifying that you will comply with the terms and conditions described in the Restrictions section below.

Pharmacist Instructions for a Patient With an Eligible Third-Party Payer: Submit the claim to the primary Third-Party Payer first, then submit the balance due to CHANGE HEALTHCARE as a Secondary Payer COB (coordination of benefits) with patient responsibility amount and a valid Other Coverage Code, (e.g., 8). The patient is responsible for the first $25 and the card pays the remainder per prescription, up to 12 fills per calendar year. Reimbursement will be received from CHANGE HEALTHCARE.

A valid Other Coverage Code is required. For any questions regarding CHANGE HEALTHCARE online processing, please call the Help Desk at 1-800-422-5604.

Restrictions: This offer is valid in the United States. This offer is not valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan, VA, DOD, TRICARE, or other federal or state health programs (such as medical assistance programs). If the patient is eligible for drug benefits under any such program or is Medicare-eligible and enrolled in employer-sponsored group waiver health plans or government-subsidized prescription drug benefit programs for retirees, the patient cannot use this offer. By using this offer, the patient and pharmacist certify that they will comply with any terms or requirements imposed on patients or providers by the health insurance to notify the health insurance plan of the existence and/or value of this offer. This offer is not valid for patients under 6 years of age. It is illegal to (or offer to) sell, purchase, or trade this offer. This offer is not transferable and is limited to one offer per person. Not valid if reproduced. Void where prohibited by law. This is not insurance. Program managed by ConnectiveRx on behalf of Zealand Pharma. The parties reserve the right to rescind, revoke, or amend this offer without notice at any time.