*If your copay exceeds $25, presentthis offer to receive savings up to $100. Some restrictions apply. See eligibility on back of the card for more details and visit www.Gralise.com.

PAY NO MORE THAN

FOR

$ * BIN# 004682PCN# CNGRP# EC95001001ID# 58685267102

Patient Instructions: Redeem this coupon ONLY when accompanied by a valid prescription for GRALISE®. This offer is not valid for prescriptions covered by or submitted for reimbursement under Medicaid, Medicare, or similar federal or state programs. Please see specific Eligibility requirements below. You are responsible for the first $25 and you will receive up to $100 off each of your next 24 Gralise prescriptions. Cardholders with questions should call 1-855-439-2821.

Pharmacist instructions for a patient with an Eligible Third Party: Submit the claim to the primary Third Party Payer first, then submit the balance due to Therapy First Plus as a Secondary Payer as copay using a valid Other Coverage Code (e.g. 8). The patient will pay the first $25, and the card pays up to the next $75 (up to 30 tablets) or $100 (31 tablets or more). Reimbursement will be received from Therapy First Plus.

Pharmacist Instructions for a Cash-Paying Patient: Submit this claim to Therapy First Plus. A valid Other Coverage Code (e.g. 1) is required. The patient will pay the first $25 and the card pays up to the next $75 (up to 30 tablets), $100 (31 tablets or more). Reimbursement will be received from Therapy First Plus.

Valid Other Coverage Code required. For any questions regarding Therapy First Plus online processing, please call the Help Desk at 1-800-422-5604.

Eligibility: This offer is valid for commercially insured patients and cash paying patients who are 18 years of age or older. This program cannot be combined with any other programs, offers, or discounts. Program managed by PSKW, LLC on behalf of Depomed, Inc. Void where taxed, restricted, or prohibited by law. Product dispensed pursuant to program rules, and federal and state laws. The parties reserve the right to amend or end this program at any time without notice. APL-GRA-0399