TO THE PATIENT

This voucher card for MOXATAG™ (amoxicillin extended-release) Tablets is being provided to you by your healthcare professional (HCP) and MiddleBrook Pharmaceuticals, Inc. Present this voucher card along with a completed and signed MOXATAG prescription to your retail pharmacy and pay no more than $20 (or less if the patient co-pay is less than $20). This voucher card may be used for one fill. Follow dosage instructions provided to you by your HCP.

To the Pharmacist

This voucher card must be accompanied by a valid prescription
This voucher card is valid for redemption at retail pharmacies only
Valid prescriber ID is required on the claim for reimbursement
If patient has third-party coverage, input card information as
secondary claim using COB fields with other coverage code 8
Patient must pay the first $20 for the cost of the prescription
Transmit claims to RxSolutions using RXBIN# 610494
For pharmacy processing questions, please call the Pharmacy Help Desk at 1-800-510-4836
Valid for one fill. No substitutions permitted

Pay no more than $20 for a prescription of MOXATAG (amoxicillin extended-release tablets)

RxBIN #	Identification #	PCN	Group #	Expires
		3333	MXT3

This voucher card is not insurance. Discount is available only at participating pharmacies.

Eligibility Criteria: 1.Individuals with prescription drug insurance: your acceptance of this offer confirms that this offer is consistent with your insurance and that you will report the value received as may be required by your insurance provider. 2.This offer is not valid for prescriptions reimbursed in whole or in part by Medicaid, Medicare, federal, or state programs (including any state prescription drug programs). 3.This voucher card is good for use only with a prescription for MOXATAG at the time the prescription is filled by the pharmacist and dispensed to the patient. 4.Offer good only in the USA and Puerto Rico at participating retail pharmacies and cannot be redeemed at government subsidized clinics. 5.This offer is not valid in Massachusetts except for cash-paying patients, or where otherwise prohibited by law. 6.MiddleBrook Pharmaceuticals, Inc., redeems this voucher card and reserves the right to rescind, revoke, or amend this offer without notice. 7.The selling, purchasing, trading, or counterfeiting of this voucher card is prohibited by law. 8.Participating patients and pharmacists understand and agree to comply with the terms and conditions of this offer as set forth above. 9.Not valid when combined with other offers. 10.The discount provided by this voucher card must not exceed the amount of an individual�s co-payment under a private or HMO insurance plan or the amount paid directly by the individual. 11.This voucher card has no cash value. 12.Claims submitted to private insurers must fully reflect all discounts, rebates or other reductions in price.

TO THE PHARMACIST

Submit claim to patient's primary insurance first. Then submit this voucher card as a secondary claim for the co-pay balance, using COB fields with other coverage code 8
Please charge the patient the balance due of $20 or their co-pay, whichever is less

Submit as a primary claim to RxSolutions using the claim processing information on this voucher card
Please charge the patient the balance due of $20

Charge the patient $20 and submit the remaining balance to be reimbursed at contracted rate
Pharmacy can mail this completed form with the pharmacy prescription receipt indicating the remaining balance to be reimbursed.

Please have the patient complete and mail this rebate form
Patient must include with the form a copy of the pharmacy receipt, indicating drug name and amount paid, and must be postmarked by the expiration date
Any personal information provided in association with this voucher card will remain confidential and will not be shared with any third party
Patient can cancel his/her registration within 30 days from the effective date of the voucher card

Address for Redemption (To receive rebate, all items must be included and voucher card completed.)
MOXATAG Rebate Offer • PO Box 42638 • Cincinnati, OH 45242-0638

1-877-MYMOXATAG www.moxatag.com www.middlebrookpharma.com

MiddleBrook Pharmaceuticals (stylized), MOXATAG1 (stylized), and M1 (stylized) are
trademarks of MiddleBrook Pharmaceuticals, Inc.