LEMTRADA Services Form

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For Patients to Complete LEMTRADA Services Form Instructions for healthcare providers enrolling patients in One to One To enroll in One to One Support Services for LEMTRADA (alemtuzumab), you and your patient are required to follow the instructions below and complete the form on page 5. After completing the form, fax it to 1-855-557-2478. Ask your patient to read the One to One Support Services description on page 2 and the authorizations on pages 3 and 4 before signing the form Discuss lab monitoring options with your patient and decide whether to participate in Sanofi Genzyme s Central Lab Program Ask your patient to complete the patient sections of the form on page 5 (be sure the patient signs the authorization sections marked with checks) You complete the rest of the form and fax it to us Within 2-3 business days, your patient will get a call from a One to One Nurse to verify benefit information. This may come as an unfamiliar number, so advise your patient to answer the phone during this period 1

What support will I get? If you sign up for these optional services, and once your enrollment is complete, you will get the following: Central Lab Program: If your healthcare provider signs up with a Sanofi Genzyme-contracted lab and you choose to participate, you will get support to help you with the recommended monitoring tests and your doctor will get updates to help track your tests. You can have monthly blood and urine samples collected: - at a nearby Patient Service Center, which One to One can help you locate if needed (collection and analysis at no cost to you); - by a traveling lab technician who will come to the location of your choice (collection and analysis at no cost to you); or - at your doctor s office, if available (check with your doctor about any costs associated with the sample collection; costs of the laboratory test analyses will be paid by Sanofi Genzyme) Personal support: You will have access to support from a dedicated One to One Nurse during regular call center hours and an on-duty nurse 24/7* Financial support services: You can get reimbursement support, benefits verification, and financial assistance, including, if you re eligible, co-pay assistance to cover your out-of-pocket costs for the medication and up to $325 of infusion administration costs per infusion day Monitoring reminders: Remember your monitoring schedule with help from us. In addition to your LEMTRADA REMS Program mandated reminders, you may also choose to receive additional monitoring support from One to One. Educational resources: Easily accessible tools are available via Internet, text, and email to help you better understand your disease Support for your family and care partners: Your family, friends, and care partners are important in your treatment journey. Helpful resources are available to them *Regular call center hours are Monday-Friday, 8:30 am-8:00 pm EST. Remember that One to One Nurses do not provide medical advice. Contact your healthcare provider with any questions about your individual health. 2

Patient Services Enrollment I am enrolling in the LEMTRADA Support Services provided by One to One (the Program ) and authorize Genzyme Corporation (Sanofi Genzyme, together with its affiliates) and its third-party business partners, vendors, and other agents ( Agents ) to provide me with services under the Program as described on page 2 and as may be added in the future. Such services include medication and adherence communications and support, reimbursement and financial support services, monthly monitoring testing, and financial assistance as part of Sanofi Genzyme s laboratory program ( Central Lab Program ), and disease and medication education and support for me and my family members and caregivers (together, the Services ). I agree that Sanofi Genzyme and its Agents may use and share with my healthcare providers, specialty pharmacies, and insurers information about me (including information sent to or created by Sanofi Genzyme as part of the Lemtrada REMS Program) in connection with the Services, including informing my healthcare providers about the Services (such as whether I am receiving the recommended laboratory monitoring tests). I also authorize Sanofi Genzyme and its Agents to contact me with information about multiple sclerosis and Sanofi Genzyme products, promotions, services, and research studies, and to ask my opinion about such information and topics, including market research and disease-related surveys. I further authorize Sanofi Genzyme and its Agents to de-identify my health information, and use it in performing research, education, business analytics, marketing studies, or for other commercial purposes. I understand that Sanofi Genzyme and its Agents may share identifiable health information with one another in order to de-identify it for these purposes and as needed to perform the Services and send the communications listed above. I understand that I do not have to enroll in the Program and that I can still receive LEMTRADA as prescribed by my physician. I may opt out of individual services offered by the Program or opt out of the Program entirely at any time by notifying a program representative by telephone (1-855-676-6326), or by sending a letter to One to One Support Services, PO Box 220790, Charlotte, NC 28222-0790. You may keep a copy of this form for your records. 3

Authorization to share health information as part of One to One Support Services I am enrolling in the LEMTRADA Support Services through One to One (the Program ) provided by Genzyme Corporation (Sanofi Genzyme) and its Agents. I authorize my healthcare providers and staff, my health insurer, any pharmacy that dispenses LEMTRADA to me (a Pharmacy ) and, if I participate in the Central Lab Program, the laboratory processing the tests and results (a Laboratory ) to disclose my health information described in this form to Sanofi Genzyme and its Agents. This health information includes information related to my medical condition and treatment (including treatment-related dates and whether I receive recommended laboratory monitoring tests), health insurance coverage and claims, prescription information, and referral to and enrollment in the Program (my Information ). The parties named above may disclose my Information to Sanofi Genzyme and its Agents to allow them to enroll me in and provide Services under the Program, send the communications described on page 3, and keep my healthcare providers informed about the Services (such as, if I participate in the Central Lab Program, whether I am receiving the recommended laboratory monitoring tests). All capitalized terms have the same meaning as those in the Patient Services Enrollment on page 3. Once my Information has been disclosed to a third party, I understand that federal privacy laws may no longer protect it from further disclosure. However, I understand that Sanofi Genzyme and its Agents agree to use and disclose my Information only as allowed by me in this Authorization or as otherwise allowed by law. I understand that my Pharmacy and my Laboratory will receive payment from Sanofi Genzyme for putting together and sending data about its dispensing of LEMTRADA to me or its scheduling or performance of laboratory tests (but not my test results). I understand that I do not have to sign this Authorization. A decision by me not to sign this Authorization will not affect my ability to obtain medical care, insurance coverage, access to health benefits, or Sanofi Genzyme medicines. However, if I do not sign this Authorization, I will not be able to receive certain services under the Program. I understand that this Authorization shall remain in effect throughout my participation in the Program unless and until I take it back. I may change my mind and take back this Authorization at any time by writing to One to One Support Services, PO Box 220790, Charlotte, NC 28222-0790, or by calling 1-855-676-6326. I understand that taking back this Authorization will mean that I cannot receive certain Services under the Program, and will not affect any use or disclosure of the Information made before my request is received and processed. You may keep a copy of this form for your records. 4

LEMTRADA SERVICES FORM Please fax this completed form to 1-855-557-2478 All fields are mandatory. This document supports the operation of the LEMTRADA REMS Program. I: PATIENT INFORMATION (PLEASE PRINT) Name (Last, First) Date of Birth (MM/DD/YYYY) Gender Male Female Street Address 1 Street Address 2 City State ZIP Code Home Number (only one is mandatory) Cell Number (only one is mandatory) Preferred Number: Home Cell Okay to leave a message: Yes No Put a check mark next to the therapies you have used in the past. Aubagio Betaseron Extavia LEMTRADA Rebif Tysabri Avonex Copaxone Gilenya Plegridy Tecfidera None Other Of the therapies above, what therapy have you used most recently? Start & Stop Dates of your most recent therapy Start Date (MM/YYYY) Stop Date (MM/YYYY) II: PATIENT SERVICES ENROLLMENT By signing below, I agree to the Patient Services Enrollment terms on page 3. Signature of Patient or Patient Representative Date Email (if you would like to receive email communications) III: AUTHORIZATION TO SHARE HEALTH INFORMATION By signing below, I certify that I have read the Authorization to Share Health Information on page 4, and authorize the disclosure of my Information to Genzyme and its Agents as described. Signature of Patient or Patient Representative Date If signed by a Patient Representative Name (Last, First) (please print) Relationship to Patient THIS SECTION SHOULD BE FILLED OUT BY YOUR HEALTHCARE PROVIDER IV: PRESCRIBER INFORMATION Prescriber Name (Last, First) NPI Number Name of Institution or Facility Tax ID Office Contact Street Address City State ZIP Code Email Address Phone Number Fax Number V: CENTRAL LAB PROGRAM Do you and your patient want to participate in the Central Lab Program? Yes No If yes, where will your patient s samples be collected? Patient Service Center Traveling lab tech Your office Other: If selecting the traveling lab tech option, please complete the EMSI Request for Services form. Any trademarks not owned by Genzyme Corporation are the property of their respective owners. Genzyme and LEMTRADA are registered trademarks of Genzyme Corporation. Sanofi and AUBAGIO are registered trademarks of Sanofi. 2016 Genzyme Corporation. All rights reserved. GZUS.LEMT.16.08.1836 5

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