VEPPANU Prescription & Enrollment Form

RIGEL ONECARE Support Options^†

Select all services you'd like to request — at least one is required.

Insurance Verification

Benefits InvestigationPrior authorization & appeal assistance

Financial Assistance

Patient Assistance ProgramFree product for eligible patients Copay AssistanceReduce out-of-pocket costs

Temporary Supply

Quick Start ProgramStart therapy without delay Bridge ProgramCoverage during interruptions

†All RIGEL ONECARE programs are subject to eligibility requirements and changes. Criteria above do not represent all criteria for each program. Must be U.S. resident or U.S. territory resident. Restrictions apply.

Specialty Pharmacy

Biologics by McKesson Onco360 In-office Dispensing

Step 1 of 6

Patient Information

Details for the patient being enrolled.

First Name*

Middle Initial

Last Name*

Date of Birth*

Sex*

Male Female Other

Address

Street Address*

City*

State*

Zip Code*

Contact

Primary Phone*

Home Mobile Work

Secondary Phone

Home Mobile Work

Email

Alternate Contact / Caregiver (optional)

Name

Primary Phone

Email

Step 2 of 6

Patient Insurance

Providing insurance coverage details and copies of insurance card(s) is optional but may help speed up the benefit investigation process.

Patient is uninsured

Primary Health Insurance

Name

Phone #

Policy ID #

Group #

Policy Holder Name

Holder DOB

Primary Prescription Insurance

Name

Phone #

Policy ID #

Rx Group #

Rx BIN

Rx PCN

Secondary Health Insurance (if applicable)

Name

Phone #

Policy ID #

Group #

Policy Holder Name

Holder DOB

Insurance Documents (optional — attach one or more; PNG / JPG / PDF)

Prescription Insurance

Drop files hereor click to browse · multiple allowed

Medical Insurance (primary, secondary, tertiary)

Drop files hereor click to browse · multiple allowed

Step 3 of 6

Diagnosis & Clinical Information

Diagnosis, biomarker status, and prior therapy history.

Diagnosis ICD-10-CM Code(s)*

ESR1 Mutation Positive*

Yes No

ER-Positive / HER2-Negative*

Yes No

Prior Therapies for Metastatic Breast Cancer (check all that apply)

Aromatase Inhibitor (anastrozole, exemestane, letrozole) CDK4/6 Inhibitor (abemaciclib, palbociclib, ribociclib) Orserdu (elacestrant) Faslodex (fulvestrant) Inluriyo (imlunestrant) Evista (raloxifene) Fareston (toremifene) Nolvadex / Soltamox (tamoxifen) Investigational / Other

Step 4 of 6

Prescriber & Prescription Authorization

Treating practitioner details and the VEPPANU prescription.

Prescriber First Name*

Prescriber Last Name*

NPI #*

State License #*

DEA #

Practice

Practice / Institution Name

Office Contact Name

Office Address

City

State

Zip

Office Phone #*

Office Fax #*

Office Contact Email*

Preferred Method of Contact

Phone Fax Email

Prescription (select at least one strength)

VEPPANU 200 mg once daily

Directions

Quantity

Refills

VEPPANU 100 mg once daily

Directions

Quantity

Refills

Substitution Allowed Dispense as Written (DAW)

Prescriber Authorization & Signature*

By signing below, I, as the treating healthcare practitioner, state that this prescription is medically appropriate for this patient and I will be supervising this patient's treatment; and that all information supplied to Rigel or its agents relating to this enrollment form is accurate and has been obtained pursuant to a separate, valid patient authorization that allows Rigel to contact this patient to provide services relating to treatment and benefit verification and/or pre-authorization.

I understand that any free product provided is for the use of this patient only; that free product may not be counted toward Medicare Part D out-of-pocket costs nor claimed for reimbursement from any third-party payer; that I am under no obligation to prescribe any Rigel drug and have not and will not receive any benefit for prescribing one; and that Rigel may revise, change, or terminate programs at any time without notice.

I, the prescriber, authorize this enrollment and agree to sign it electronically via DocuSign after submitting. I confirm the dispensing preference selected above.

Step 5 of 6

Review & Submit

Confirm the information below before submitting.

Support Requested

Patient

Name

Date of Birth

Sex

Primary Phone

Address

Insurance & Documents

Uninsured

Primary Health Plan

Primary Rx Plan

Secondary Health Plan

Documents Attached

Diagnosis & Clinical

ICD-10-CM

ESR1 Mutation Positive

ER+ / HER2-

Prior Therapies

Prescriber & Prescription

Name

NPI #

State License #

Preferred Contact

Strength(s)

Dispense

Prescriber Authorization and Signature

Authorization to Sign

Dispensing Preference Confirmed

Step 6 of 6

VEPPANU Prescription & Enrollment Form

RIGEL ONECARE Support Options†

Patient Information

Patient Insurance

Diagnosis & Clinical Information

Prescriber & Prescription Authorization

Review & Submit

Enrollment Submitted

RIGEL ONECARE Support Options^†