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What is the Trial Voucher Program?

This program offers your eligible patients new to SEMGLEE or Insulin Glargine (insulin glargine-yfgn) Injection a free trial of five pens or two vials of either SEMGLEE or Insulin Glargine (insulin glargine-yfgn) Injection. Patients must be uninsured or insured with coverage for SEMGLEE or Insulin Glargine (insulin glargine-yfgn) Injection. Limit one Trial Voucher per eligible patient.

Please fill in the following information about you and your patient. This information will be used to request a Trial Voucher for your eligible patients.

Please answer the highlighted question(s) in red.

Please complete the information below about your HCP office. (Information may be disclosed for state law reporting purposes.)

^* First Name

^* Last Name

^* Business Address

^* City

^* State

^* Zip Code

^* State License #

^* Expiration Date

NPI Number, if applicable

I certify, by checking this box, that I am requesting this voucher to allow my medically-appropriate patient to try SEMGLEE or Insulin Glargine (insulin glargine-yfgn) Injection that I have prescribed for them to allow them to evaluate the efficacy and tolerability of the drug product. The patient is not currently using SEMGLEE or Insulin Glargine (insulin glargine-yfgn) Injection. I will not sell, purchase, trade, barter, return for credit or offer to do so, or seek reimbursement for any drug product obtained with this voucher. I agree that I will inform my patient that (i) the patient is under no obligation to purchase product if the patient chooses to use the product voucher, and (ii) the patient must not seek reimbursement for drug product obtained with this voucher.

I certify, by checking this box, that the patient receiving the Trial Voucher has insurance with coverage for SEMGLEE or Insulin Glargine (insulin glargine-yfgn) Injection, or the patient is uninsured.

Biocon Biologics Limited and its affiliates and subsidiaries are fully committed to protecting the information relating to identified or identifiable natural persons ("Personal Data") that we process.

The Biocon Biologics Privacy Notice describes our collection, use, disclosure, and retention of Personal Data in relation to our websites, apps, services, and platforms, and your use of them, our marketing and provision of products and services, our interactions with you in-person, by calling us, or by mail, and otherwise during the operation of our business. The Notice also explains the ways in which you may, under applicable laws, be able to control our processing of your Personal Data and exercise other rights.

Limit one voucher redemption per eligible patient. Voucher must be accompanied by a valid, signed prescription for five pens or two vials of either SEMGLEE or Insulin Glargine (insulin glargine-yfgn) Injection. Not valid for refills.

Terms and Conditions:

Patients must be new to SEMGLEE and Insulin Glargine (insulin glargine-yfgn) and have not previously filled a prescription for SEMGLEE or Insulin Glargine (insulin glargine-yfgn). Void where prohibited by law. Product dispensed only pursuant to these terms and conditions of voucher. Patients must either be uninsured; or have commercial insurance with coverage for SEMGLEE or Insulin Glargine (insulin glargine-yfgn), or participate in any state or federally funded healthcare program, including but not limited to any state pharmaceutical assistance program, Medicare (Part D or otherwise), Medicaid, Medigap, VA or DOD, or TRICARE with coverage for SEMGLEE or Insulin Glargine (insulin glargine-yfgn). This offer is not valid for commercially insured patients without coverage for SEMGLEE or Insulin Glargine (insulin glargine-yfgn) or patients that participate in any state or federally funded healthcare program without coverage for SEMGLEE or Insulin Glargine (insulin glargine-yfgn). Neither pharmacist nor patient may submit a claim for product dispensed pursuant to this voucher to any public or private third-party payer or any federal or state health care program for reimbursement. Patient must not count free product dispensed pursuant to this voucher towards any out-of-pocket cost obligations, such as Medicare Part D True Out-of-Pocket Costs (TrOOP). Offer not valid if reproduced or submitted to any other payer. This voucher can be redeemed only by patients or patient guardians who are 18 years of age or older. This voucher cannot be combined with any other savings, cash discount card, free trial or similar offer for the specified prescription. This voucher is not intended to be used by a patient who receives a drug sample. This voucher is not transferable. This free trial is not health insurance. Offer good only in the U.S. and its territories. No purchase is necessary. Patients have no obligation to continue use of SEMGLEE or Insulin Glargine (insulin glargine-yfgn). It is illegal for any person to sell, purchase or trade, or offer to sell, purchase or trade, or to counterfeit this voucher. Prescriber ID# required on prescription. McKesson retains the right to review all records and documentation relating to the filling/dispensing of product. Biocon Biologics Inc., reserves the right to rescind, revoke or amend this offer at any time.

NOTICE: Data related to your use of this voucher may be collected, analyzed and shared with Biocon Biologics Inc., for market research and other purposes related to assessing its programs. Data shared with Biocon Biologics Inc., will be aggregated and de-identified, meaning it will be combined with data related to other savings card and voucher redemptions and will not identify you.