HADLIMA™

If you have been prescribed an Organon medicine, you may be eligible for the program* if all 3 of the following conditions apply:

1. You are a US resident and have a prescription for an Organon product from a health care provider licensed in the United States.^†

   AND

2. You do not have insurance or other coverage for a prescription medicine.

   AND

3. You cannot afford to pay for your medicine. You may qualify for the patient assistance program if you have a household income of $78,250 or less for individuals, $105,750 or less for couples, or $160,750 or less for a family of 4.^‡

The Organon Patient Assistance Program is primarily designed to help those who do not have insurance coverage; however, if you have insurance coverage, but still are having trouble paying for your medicine, you may still be eligible, provided that your income is not above a set limit and you meet certain other medical and/or insurance criteria.

* Offered through the Organon Patient Assistance Program Inc.

^† You do not have to be a US citizen. Legal residents of the United States, including US territories, are also eligible.

^‡ For income limits in Alaska and Hawaii, please call 888-727-0015.

If you believe that you meet the eligibility criteria for the Organon Patient Assistance Program and you have received a prescription for HADLIMA, proceed to Step 4 to download an enrollment form or call toll-free 888-727-0015 8 AM to 8 PM ET to obtain an enrollment application. After downloading the application or receiving your application in the mail, follow these simple steps to submit your enrollment form for your free Organon medicine:

1. Complete ALL information on the enrollment form.

• You may fill in the fields online and print it.

  OR

  You may print out the form and fill it out by hand using a black ballpoint pen.

2. Take the completed application to your physician/prescriber. Both you and the physician/prescriber MUST sign the application.

3. Have your physician/prescriber write your prescription(s) in Section 4 of the application.

• Each prescription may not exceed an 84-day supply at a time, with a maximum of 3 refills.

  Each application is valid for up to 12 months; after 12 months a new application will be required. Under certain circumstances, enrollment may be limited to a calendar year.

4. Fax the completed application to 833-520-1491.

   • If fax is not available, please mail a completed application to:

     Organon Patient Assistance Program
     P.O. Box 991624
     Louisville, KY 40269

Please Note:

• Once a completed application and any requested supporting documentation has been received and processed, you and your provider will be notified of the enrollment decision. Missing information or an incomplete application will delay an enrollment decision.
• Section 4 of the application is your prescription. Your physician/prescriber does not need to write your prescription on a separate prescription form.
• Once you have been enrolled, you will be contacted by the Organon Patient Assistance Program to provide consent for shipment. Your medication will be sent to your home address unless otherwise requested by the physician/prescriber in Section 1 of the application.
• For additional applications or assistance, please call 888-727-0015.

Please download and complete the enrollment form (Application). You may call 888-727-0015 if you need assistance.

Fax the completed application to 833-520-1491.

• If fax is not available, please mail a completed application to:

  Organon Patient Assistance Program
  P.O. Box 991624
  Louisville, KY 40269