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Which medication are you requesting co-pay assistance for?

MAVENCLAD^® (cladribine) 10 mg tablets

Rebif^® (interferon beta-1a) subcutaneous injection

Please see MAVENCLAD full Prescribing Information and Medication Guide, including serious side effects at links
above.

Please see Rebif full Prescribing Information and Medication Guide at links above.

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US-MULNI-00437 07/26

MS LifeLines Co-Pay Assistance Program

All field(s) are required unless otherwise specified.