APALY HEALTH INC.

1. Prescription Routing Consent

1.1 Authorization to Receive and Route Prescriptions. By enrolling in the ApalyRx program and accepting the Terms of Use, you authorize Apaly Health Inc. and ApalyRx LLC to receive prescriptions transmitted electronically from your prescribing provider on your behalf, and to route and transfer those prescriptions to the designated Dispensing Pharmacy for fulfillment. Prescriptions may be transmitted to ApalyRx LLC automatically via NCPDP SCRIPT or other standard electronic prescription formats without requiring your separate approval for each individual prescription, consistent with your enrollment authorization.

1.2 Pharmacy Selection. You acknowledge that you have the right to have your prescription filled at a pharmacy of your choice. However, program pricing available through the ApalyRx program is only available when your prescription is dispensed by the designated Dispensing Pharmacy for the applicable program. By enrolling and accepting these terms, you consent to your covered medications being routed to and dispensed by the designated Dispensing Pharmacy in order to access program pricing. You may request transfer of your prescription to a pharmacy of your choice at any time, in which case standard plan benefit pricing will apply.

1.3 Dispensing Pharmacy Partners. The Dispensing Pharmacies designated under the program are state-licensed pharmacies independent of Apaly Health Inc. and ApalyRx LLC. A current list of designated Dispensing Pharmacy partners is available at apalyrx.com/legal. Apaly Health may add or change Dispensing Pharmacy partners from time to time. You will be notified via SMS or through your account of any change that affects your active prescriptions.

1.4 No Automatic Refills. Automatic refills are not permitted under the program. Each dispense requires a new patient request. You will be notified via SMS or through the platform when a new request is needed.

1.5 No Clinical Direction. Apaly Health and ApalyRx LLC do not direct, influence, or interfere with the clinical judgment of your prescribing provider. All decisions about your medical care, including which medications are prescribed and at what dose, are made solely by your provider. Your provider is not required to route prescriptions through the program and retains full clinical independence.

2. Government Program Exclusion

2.1 Ineligibility for Government Program Beneficiaries. You are not eligible to participate in program pricing available through the ApalyRx platform if you are a primary or secondary beneficiary of any Government Program. For purposes of this document, "Government Program" means Medicare, Medicaid, TRICARE, the Veterans Administration Federal Supply Schedule, the 340B program, a Qualified Retiree Prescription Drug Plan, an Employer Group Waiver Plan, a Health Care Exchange plan, or any other federal or state health care program, entitlement program, or public assistance program.

2.2 Representation and Warranty. By enrolling in the program and accepting these terms, you represent and warrant that you are not a beneficiary of any Government Program in any payor position, primary or secondary, with respect to the covered medications. If you become a Government Program beneficiary after enrollment, you must notify Apaly Health immediately at privacy@apalyrx.com and stop using the program for affected medications.

2.3 Out-of-Pocket Acknowledgment. You acknowledge and agree that any cost you incur in purchasing covered medications through the ApalyRx program will not count toward your out-of-pocket expense for any Government Program. Cost share amounts collected under this program are commercial payments and are not submitted to, and cannot be applied against, any Government Program deductible or out-of-pocket maximum.

2.4 No Government Program Claims. You agree that you will not submit, and will not cause any other person or entity to submit, any claim regarding covered medications dispensed through the ApalyRx program to any Government Program. This prohibition applies regardless of whether you believe a claim might otherwise be permissible.

3. Program Exclusivity and No Additional Supplier Programs

For purposes of this Section, "Program Supplier" means any manufacturer, pharmacy, distributor, or other entity that supplies products or provides pricing to eligible members through the ApalyRx program.

3.1 Exclusivity of Program Pricing. Covered medications purchased through the ApalyRx program at Program Supplier pricing are subject to the exclusivity requirements of the applicable program. Specifically, members enrolled in an Eligible Plan who access covered medications through the ApalyRx program at Program Supplier pricing are not eligible for any additional Program Supplier assistance or discount programs for those same medications from the same Program Supplier during the same period.

3.2 Excluded Additional Programs. Additional programs that cannot be combined with ApalyRx program pricing for the same medication include, without limitation:

• Copayment assistance or buy-down programs offered by the applicable Program Supplier
• eVoucher programs or electronic coupon programs offered by the applicable Program Supplier
• Patient assistance programs offered by the applicable Program Supplier
• Cash discount offers or promotions offered by the applicable Program Supplier
• Any other Program Supplier-sponsored discount, subsidy, or financial assistance program for the same medication

3.3 Program Supplier Specific Requirements. Individual Program Suppliers may have additional program requirements that apply to members accessing their products through the ApalyRx program. Those requirements are set forth in the Program Supplier Participation Terms at apalyrx.com/legal and are incorporated into this consent by reference. You are responsible for reviewing those requirements before using the program for a specific Program Supplier's product.

3.4 No Effect on Other Medications. The exclusivity rules in this Section 3 apply only to the specific covered medications for which you are receiving Program Supplier pricing through the ApalyRx program. They do not affect your eligibility for any Program Supplier programs or assistance programs for other medications not covered by the ApalyRx program.

4. Cost Share and Payment

4.1 Cost Share Notification. Before your prescription is dispensed, Apaly Health will notify you via SMS of your applicable cost share amount as determined by your health plan's benefit design. You will have the opportunity to confirm or decline the transaction before your prescription is processed.

4.2 Cost Share Collection. Cost share payments are collected by Apaly Health through the platform's payment processor, Stripe, Inc., in accordance with your health plan's benefit design. Dispensing Pharmacy partners will not collect cost share directly from you. Apaly Health is solely responsible for cost share collection and for remitting applicable amounts to the Dispensing Pharmacy as required.

4.3 No Fee Markup. Apaly Health will not markup or increase any dispensing fees charged by Dispensing Pharmacies in amounts billed to you for cost share.

4.4 Taxes. Applicable taxes, if any, will be included in amounts collected from you consistent with applicable law and the terms of your health plan.

4.5 Refunds and Appeals. Cost share payment refunds and benefit appeals are subject to your health plan's policies. Contact your employer or health plan administrator for information on the appeals process. Apaly Health does not adjudicate benefit appeals and cannot modify coverage determinations made by your health plan or its designated administrator.

5. Dispensing Pharmacy Partner Specific Consents

5.1 General Dispensing Pharmacy Terms. By accepting these terms, you agree to the General Dispensing Pharmacy Terms available at apalyrx.com/legal, which apply to all Dispensing Pharmacy partners that do not have their own separate member-facing terms.

5.2 Partners with Specific Forms. Certain Dispensing Pharmacy partners require their own specific consent forms as a condition of dispensing medications under their programs. Those partner-specific forms are available at apalyrx.com/legal. By accepting these terms, you accept those partner-specific forms for any prescriptions routed to those partners. Those forms are incorporated herein by reference and are not modified by this consent. If a partner's form conflicts with this document on a matter specific to that partner's program, the partner's form governs for that matter.

5.3 Patient Right to Choose Pharmacy. You retain the right at all times to request that your prescription be transferred to a pharmacy of your choice. Exercising this right means that program pricing may not be available for that prescription, and standard plan benefit pricing will apply. To request a transfer, contact Apaly Health at privacy@apalyrx.com or through your account at apalyrx.net.

6. Own Use and Product Integrity

6.1 Own Use Only. Covered medications dispensed through the ApalyRx program are for your own lawful personal use only. You may not sell, transfer, share, or provide program-dispensed medications to any other person for any purpose.

6.2 Proper Use. You agree to use covered medications only as directed by your prescribing provider and consistent with applicable law. You agree not to use covered medications for resale or any commercial purpose.

6.3 Reporting Misuse. If you become aware of any misuse or diversion of program-dispensed medications, you agree to notify Apaly Health promptly at privacy@apalyrx.com.

7. Program Changes and Termination

7.1 Changes to Dispensing Pharmacies. Apaly Health may add, change, or remove Dispensing Pharmacy partners at any time. If a change affects your active prescriptions, Apaly Health will notify you via SMS or through your account and will work with you to transfer your prescriptions to a new designated pharmacy or to standard channels.

7.2 Changes to Manufacturer Programs. Participating Manufacturers may modify or terminate their programs at any time. If a manufacturer terminates or modifies a program in a way that affects your coverage, Apaly Health will notify you and your prescriptions will be transferred to available program channels or standard benefit channels.

7.3 Your Right to Withdraw. You may withdraw from the ApalyRx program at any time by contacting Apaly Health at privacy@apalyrx.com or through your account at apalyrx.net. Withdrawal does not affect prescriptions already in process. Upon withdrawal, your prescriptions will be transferred to standard pharmacy channels.

7.4 Effect of Withdrawal. Withdrawal from the program does not affect your right to obtain your medications through standard pharmacy channels or your coverage under your health plan's standard benefits. It does not constitute revocation of your HIPAA Authorization, which must be revoked separately as described in the HIPAA Authorization document at apalyrx.com/legal.

8. Member Acknowledgments

By accepting the Apaly Health Inc. Terms of Use and this Patient Consent and Acknowledgment, you confirm that you have read, understood, and agree to all of the following:

• You understand that participation in the ApalyRx program is voluntary and that you may obtain your medications through standard pharmacy channels at any time
• You understand that program pricing available through the program is only available when your prescription is dispensed by a designated Dispensing Pharmacy under the applicable program
• You understand and acknowledge that you are not a beneficiary of any Government Program, and that program pricing cannot be combined with Government Program benefits
• You understand that covered medications dispensed through the program cannot be combined with additional Program Supplier assistance programs such as copay assistance or patient assistance programs for the same medication
• You understand that any cost share you pay through the program does not count toward any Government Program out-of-pocket maximum
• You understand that you will not submit, and will not permit any other person to submit, claims for program-dispensed medications to any Government Program
• You understand that covered medications are for your own personal use only and may not be resold or distributed
• You understand that certain Dispensing Pharmacy partners have their own specific consent requirements available at apalyrx.com/legal, and that your acceptance of these terms constitutes your acceptance of those partner-specific forms for applicable prescriptions
• You understand that Apaly Health and ApalyRx LLC do not dispense medications, do not make clinical decisions, and do not adjudicate benefits
• You understand that you may withdraw from the program at any time and that withdrawal will result in transfer of your prescriptions to standard channels