_{**Program Enrollment Consent: UCB Direct for BRIVIACT Terms and Conditions}

_{UCB Direct helps facilitate access to BRIVIACT® (brivaracetam) CV for patients that choose to stay on branded therapy after generic versions of the product become commercially available. The program helps patients understand their insurance coverage for BRIVIACT and provides patients with options for filling their BRIVIACT prescription through the program either under the patient’s insurance or at a discounted cash price. 
By enrolling in UCB Direct for BRIVIACT, you acknowledge that the program administrator will use your information to complete a benefits investigation and assess your out-of-pocket costs for filling your BRIVIACT prescription under your insurance. Patients that elect to purchase BRIVIACT through the program at a discounted cash price acknowledge that the prescription will be filled completely outside any commercial or government insurance benefit and cannot be counted toward any deductible or TrOOP calculations. Medicare enrollees further acknowledge that they will not seek coverage for the drug through their Medicare Part D benefit for the remainder of their insurance plan’s benefit year, and that the program administrator will share information about the patient’s participation in the discounted cash price program with the patient’s insurance plan. The program is available only for BRIVIACT prescriptions for the tablet or oral solution formulations. Patients must have a valid prescription consistent with the FDA-approved product labeling for BRIVIACT to participate. The program is available to residents of the continental United States of America, including the District of Columbia. The program is not available where prohibited by law. The program is not health insurance. Limitations may apply. Manufacturer reserves the right to rescind, revoke, or amend this program without notice.}