To receive co-pay assistance of up to $250 for each prescription filled, please accurately answer the questions below:

Patient Name:

Email Address:

Patient Address:

City:

State:

ZIP Code:

Cell Phone:

Prescriber Name:

Please see Important Safety Information, including Boxed Warning and full Prescribing Information, at https://www.otrexup.com/.

Are you using this medication to treat any of the following?

The management of selected adults with severe, active rheumatoid arthritis (RA) (ACR criteria)

Children with active polyarticular juvenile idiopathic arthritis (pJIA}, who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs)

In adults for the symptomatic control of severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy, but only when the diagnosis has been established, as by biopsy and/or aner dermatologic consultation. It is important to ensure that a psoriasis “flare” is not due to an undiagnosed concomitant disease affecting immune responses.

To insure each patient is benefiting from the Otrexup Total Care Co-Pay Assistance Program, Antares Pharma, Inc. would like to notify you about updates to the program by email. Please see Important Safety Information when the coupon is printed.

OTREXUP TOTAL CARE CO-PAY ASSISTANCE PROGRAM