For your Ranexa® (ranolazine extended-release tablets) prescription

Ranexa Connect™ Patient Assistance Program

Patient ApplicationThank you for your interest in the Ranexa Connect Patient Assistance Program (PAP). For a patient to be considered eligible for the Program all of the following criteria must be met: You must be a legal resident of the United States

Your total family household income must be at or below 300% of the United States Federal Poverty Level

– Federal Poverty Level guidelines are updated annually. For information on the current Federal Poverty Level, visit www.aspe.hhs.gov/poverty.

If you are uninsured, enrolled in a Medicare Part D plan, or have private insurance, you may be eligible for the Program. Individuals enrolled in other government-funded prescription plans (such as Medicaid, VA, Tricare, or State Assisted Programs) are NOT eligible to participate in the Program.

Application ProcessFill out the attached application completely, making sure to sign and date the application. We will review the application on a case-by-case basis. Gilead Sciences, Inc, reserves the right to modify or discontinue the PAP at any time.

Required DocumentationIn order for your application to be considered complete, you must provide all of the following documentation and send it to the address at the bottom of this page. A completed and signed application form filled out and signed by both you and your Healthcare Provider

A completed prescription form, provided in this application

A copy of your insurance card (if you are a Medicare patient, enclose a copy of the Medicare Part D Prescription Plan ID card)

Proof of income. Attach a copy of your most recent year federal tax return or financial documentation (IRS Form 1040, 1040EZ, 4506T, 1099 Social Security, or Disability Statement)

Place all required documents together in a stamped envelope and mail to:

Ranexa Connect Patient Assistance Program PO Box 13185

La Jolla, CA 92039-3185

If you have any questions or need help with your application, please call a Ranexa Connect Patient Assistance Counselor at 1-888-726-3925.

Ranexa is a registered trademark of Gilead Palo Alto, Inc. © 2011 Gilead Sciences, Inc. All rights reserved. RC8687 4/11

Ranexa® (ranolazine extended-release tablets)

Patient Assistance Program ApplicationThe Ranexa Connect Patient Assistance Program is sponsored by Gilead Sciences, Inc, which provides the medication Ranexa® (ranolazine extended-release tablets) to qualified patients at no charge. There is one section of the application that must be completed by the patient and one section to be completed by the Healthcare Provider/Physician who writes the prescription. Please call the Ranexa Connect Patient Assistance Program at 1-888-726-3925 if you have any questions.

New Patient Renewal Patient

A. Information to Be Completed by Patient

Patient Name

Patient Address Apartment

City State ZIP

Telephone Number Other Telephone Number

Fax Number Best Time to Call

E-mail

Date of Birth (month/day/year) Gender Male Female

Are you enrolled in any benefit program that helps pay for prescription drugs? Yes No

Are you enrolled in Medicare? Yes No Are you a veteran? Yes No

Are you enrolled in a Medicare prescription drug coverage program (also known as Part D)? Yes No

Are you enrolled in Medicaid? Yes No Number of dependents in your household

Did you file a federal tax return for the most recent tax year? Yes No

Total Annual Household Income (Attach proof of income for each source listed)

Salary/Wages: $ Social Security Disability: $ Rental Income: $

Pension/Retirement: $ Social Security Retirement: $ Unemployment: $

Workers Compensation: $ Supplemental Security Income: $ Alimony/Child Support: $

Veterans Benefits: $ Other: $ TOTAL: $

Household Size (Number of persons who contribute to or are dependent on patient's household income):

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Patient Authorization to Use and Disclose Health InformationGilead Sciences, Inc, (“Gilead”) sponsors the Ranexa Connect Patient Assistance Program (“Ranexa Connect” or “Program”) to assist patients in obtaining Gilead’s product Ranexa (ranolazine extended-release tablets). Ranexa Connect offers reimbursement support services, including answers for general (reimbursement) insurance questions, benefits investigations, searches for alternative coverage, assistance with prior authorizations and appeals, and a patient assistance program for qualified individuals. In order for me to obtain services under the Program, I understand that Gilead, its affiliates, and authorized agents (including third-party administrators) will need to review, use, and disclose information about me, my health insurance coverage, and my medical diagnosis and treatment (including my use or need for Gilead’s product, Ranexa). I request and authorize my doctor and other healthcare professionals (“Doctor(s)”) and my health plan or insurance company (“Insurer(s)”) to give Gilead, its affiliates, and authorized agents (including third-party administrators) information based on this Authorization. I understand that Gilead may use this information to contact me by mail, telephone, and/or e-mail about my experience with Ranexa Connect. Once this information is disclosed, it may no longer be protected by federal or state privacy laws and, as a result, may be further disclosed. However, Gilead, its affiliates, and authorized agents (including third-party administrators) will use and disclose such information solely to: (i) facilitate my participation in the Program; (ii) administer, assess, and improve the Program; (iii) account for my withdrawal if I decide to stop participating in the Program; (iv) track general use of Gilead’s product; and (v) respond to request(s) for disclosure as required by law. I understand that I need to sign and return this Authorization to take part in the Program. I also understand that I can refuse to sign and return this Authorization. If I do not sign and return this Authorization, my decision will not affect my ability to obtain any treatment, payment for treatment, insurance enrollment, or eligibility for insurance benefits. However, if I do not sign this Authorization, Gilead will not be able to verify my insurance coverage for Gilead's product or determine if I am eligible to participate in an available patient assistance program, and I may have to pay for Gilead's product myself. I also understand that I can cancel this Authorization at any time by writing to Gilead Sciences, Inc, c/o Ranexa Connect, PO Box 13185, La Jolla, CA 92039-3185. If I cancel this Authorization, then Doctor(s) and Insurer(s) will stop providing my information to Gilead, its affiliates, and authorized agents (including third-party administrators) and prevent further use or disclosure of my information by Gilead, its affiliates, and authorized agents (including third-party administrators) after the date my letter of revocation is received and processed by them; however, I cannot cancel actions already taken when relying on this signed Authorization. I am entitled to a copy of this signed Authorization, which expires 10 years from the date it is signed by me.

Patient Signature X DatePatient Guardian Signature (if applicant is under 18) or other authorized person (specify relationship):

X Relationship Date

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B. Healthcare Provider/Prescriber Information to be completed by the practitioner who writes the prescription

Prescription

THIS IS THE PRESCRIPTION. PHYSICIAN SHOULD COMPLETE THE PRESCRIPTION AND THE PRODUCT INFORMATION BELOW. IF YOU ATTACH AN ORIGINAL PRESCRIPTION, PLEASE MAKE SURE IT INCLUDES THE INFORMATION BELOW. PLEASE PRINT.

Patient Name

Patient Address Apartment

City State ZIP

Date of birth (month/day/year) Telephone Number

Ranexa 500 mg 1000 mg Quantity dispensed 90 day Other

Check appropriate box below and provide original signature (we cannot accept signature stamps):

Dispense as written. Physician/Prescriber’s Signature

Substitution permissible. Physician/Prescriber’s Signature

State License Number Date

Ship product to: Patient’s Home Other (please specify)

ALLERGIES: None Please specify

CURRENT MEDICATION(S) BEING TAKEN BY THE PATIENT:

Prescriber CertificationBy signing this form, I certify that I am prescribing the aforementioned medication for a patient participating in the Ranexa Connect Patient Assistance Program. I certify that this prescription medication is medically indicated for the patient identified in Section B and that it will be used as directed. I certify that I will be supervising the patient’s treatments and verify that the information provided is complete and accurate to the best of my knowledge. I acknowledge that I shall not seek reimbursement for any medication dispensed hereunder from any government program or third-party insurer.

Prescriber’s Name (please print) Date

Address DEA No.

City State ZIP Phone

License No. UPIN Fax

Physician Office Contact

I authorize Gilead Sciences, Inc, and Covance as my designated agents and on behalf of my patient to forward the prescription, by fax or other mode of delivery, to the pharmacy chosen by Gilead Sciences, Inc, to dispense free goods.

Prescriber’s Original Signature Date

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