Approved Use: Aimovig® is a prescription medicine used for the preventive treatment of migraine in adults.

For eligible commercially insured patients
FOR ELIGIBLE COMMERCIALLY INSURED PATIENTS
Step 1 of 4
Confirm Your Eligibility

What type of insurance do you use to pay for your Aimovig® prescription at the pharmacy?

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Health insurance you or a family member purchased and/or receive through an employee, healthcare exchange, or commercial plan through the federal employees health benefits (FEHB) program
?
Includes Medicare Part D, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs

Are you eligible for Medicare but receive prescription drug coverage from a former employer, union, or welfare plan?*

Step 2 of 4

Enroll to Get Your Card

Please provide the information below to activate your Copay Card and participate in AimAlly support programs.

Required information*

Please enter your first name
Please enter your last name
Please select your sex
If you or your loved one is under the age of 18, please call AimAlly Support (1-833-AIMOVIG) to complete enrollment.
Select your month
Select your day
Select your year
Please enter your address
Please enter your city
Select your state
Please enter your ZIP code
Please enter at least one phone number

Please provide at least one phone number*

Please enter your email address
Please confirm your email address
Step 4 of 4
Patient Authorization and Consent

I give permission for my healthcare providers, pharmacies, service providers and their contractors (“Healthcare Providers”), and health insurers and their contractors (“Insurers”), to disclose my personal information, including information about my health insurance benefits, prescriptions, my medical condition and history, adherence to my treatment, and my general health (“personal information”) to Amgen Inc., its affiliates, business partners, and agents (“Amgen”) for the following purposes:

Give permission for my healthcare providers, pharmacies, service providers and their contractors ("Healthcare Providers"), and health insurers and their contractors ("Insurers"), to disclose my personal information, including information about my health insurance benefits, prescriptions, my medical condition and history, adherence to my treatment, and my general health ("personal information") to Amgen Inc., its affiliates, business partners, and agents ("Amgen") for the following purposes:

(i) help to verify or coordinate insurance coverage or otherwise obtain payment for my treatment with Aimovig® (erenumab-aooe);
(ii) coordinate my receipt of and payment for Aimovig®;
(iii) facilitate my access to Aimovig®;
(iv) provide me with information about Amgen products, disease education and awareness and management programs, and promotional materials related to my condition or treatment;
(v) manage the AimAlly support program;
(vi) If I am eligible, coordinate the Aimovig® Copay Card program, including managing and communicating with me about the copay support options available to me;
(vii) provide me with medication reminders and support; and
(viii) conduct quality assurance, surveys, and other internal business activities in connection with the AimAlly support program and other related programs.

I give permission to Amgen to disclose my personal information to my Healthcare Providers for the purposes described above. I understand that my Healthcare Providers and Insurers may receive remuneration (payment) from Amgen in exchange for disclosing my personal information to Amgen and/or for providing me with therapy support services.

I understand that once my personal information is disclosed, it may no longer be protected by federal privacy law. I understand that I may refuse to sign this authorization. I also may revoke (cancel) or get a copy of this authorization at any time by calling 833-246-6844 or writing to PO Box 2205, Morristown, NJ 07962. I also understand that if a Healthcare Provider or Insurer is disclosing my personal information to Amgen on an authorized, ongoing basis, my cancellation with Amgen will be effective with respect to any such Healthcare Provider or Insurer as soon as they receive notice of my cancellation.

My refusal or future revocation will not affect my medical treatment or insurance benefits; however, if I revoke this authorization, I may no longer be able to participate in the AimAlly support program and related programs. If I revoke this authorization, Amgen will stop using or sharing my information (except as necessary to end my participation in the program), but my revocation will not affect uses and disclosures of personal information previously disclosed in reliance upon this authorization. I understand that this authorization will remain valid for 5 years after the date of my signature, unless I revoke it earlier. I also understand that the AimAlly support program may change or end at any time without prior notification.

I agree to be contacted by Amgen by mail, email, telephone calls and text messages at the numbers and address(es) provided on this Form for all purposes described in this Patient Authorization. I also agree to be contacted by Amgen and others on its behalf by telephone calls and text messages made by or using an automatic telephone dialing system or pre-recorded voice, at the number(s) provided on this form, for all nonmarketing purposes, including but not limited to sending me materials and asking for my participation in surveys.

I confirm that I am the subscriber for the telephone number(s) provided and the authorized user for the e-mail address(es) provided, and I agree to notify Amgen promptly if any of my number(s) or address(es) change in the future. I understand that my wireless service provider’s message and data rates may apply. I understand that Amgen does not permit my personal information to be used by its business partners for their own separate marketing purposes. I understand and agree that personal information transmitted by e-mail and cell phone cannot be secured against unauthorized access.

I certify that I am the patient or its legal representative and that I have read and agree to the above patient authorization.*

Step 4 of 4
Program Details and Terms and Conditions

Summary of Terms and Conditions

It is important that every patient read and understand the full Aimovig® (erenumab-aooe) Copay Card Terms and Conditions. The following summary is not a substitute for reviewing the Terms and Conditions in their entirety.

As further described below, in general:

  • The Aimovig® Copay Card is open to patients with commercial insurance, regardless of financial need. The program is not valid for patients whose Aimovig prescription is paid for in whole or in part by Medicare, Medicaid, or any other federal or state programs. It is not valid for cash-paying patients or where prohibited by law. (See ELIGIBILITY section below.)
  • With the Aimovig® Copay Card, a commercially insured patient who meets eligibility criteria may pay as little as a $5 copay per month for their Aimovig monthly out-of-pocket costs. Monthly out-of-pocket costs include co-payment, co-insurance, and deductible out-of-pocket costs. Amgen will pay the remaining eligible out-of-pocket costs on behalf of the patient up to a Maximum Monthly Benefit, a Maximum Annual Program Benefit and/or the Patient Total Program Benefit. Patients are responsible for all amounts that exceed these limits. (See PROGRAM DETAILS section below.)
  • The program provides assistance up to a Maximum Monthly Benefit except that the Maximum Monthly Benefit will not apply to the first 2 uses of the Aimovig® Copay Card for Aimovig in any given calendar year.
  • Offer is subject to change or discontinuation without notice.
  • The Aimovig® Copay Card provides support up to the Maximum Monthly Benefit, the Maximum Annual Program Benefit and/or Patient Total Program Benefit. If a patient's commercial insurance plan imposes different or additional requirements on patients who receive Aimovig® Copay Card benefits, Amgen has the right to reduce or eliminate those benefits. Whether you are eligible to receive the Maximum Monthly Benefit, Maximum Program Benefit or Patient Total Program Benefit is determined by the type of plan coverage you have. Please ask your AimAlly Support Team to help you understand eligibility for the Aimovig® Copay Card, and whether your particular insurance coverage is likely to result in your reaching the Maximum Monthly Benefit, the Maximum Annual Program Benefit, or your Patient Total Program Benefit, by calling 1-833-AIMOVIG (1-833-246-6844). (See PROGRAM BENEFITS section below.)

I. ELIGIBILITY

Eligibility Criteria: Subject to program limitations and terms and conditions, the Aimovig®(erenumab-aooe) Copay Card is open to patients who have an Aimovig prescription and who have commercial or private insurance, including plans available through state and federal healthcare exchanges. This program helps eligible patients cover out-of-pocket costs related to Aimovig, up to program limits. There is no income requirement to participate in this program.

This offer is not valid for patients whose Aimovig prescription is paid for in whole or in part by Medicare, Medicaid, or any other federal or state programs. It is not valid for cash-paying patients or where prohibited by law. A patient is considered cash-paying where the patient has no insurance coverage for Aimovig or where the patient has commercial or private insurance but Amgen in its sole discretion determines the patient is effectively uninsured because such coverage does not provide a material level of financial assistance for the cost of an Aimovig prescription. This offer is only valid in the United States, Puerto Rico, and the US territories.

II. PROGRAM BENEFITS

The Aimovig® Copay Card helps provide out-of-pocket support to eligible patients for their Aimovig prescription up to program limits. See PROGRAM DETAILS for full description.

The Aimovig® Copay Card offer does not cover out-of-pocket costs for any patient whose selected coverage option under their commercial insurance plan does not apply Aimovig® Copay Card payments to satisfy the patient's co-payment, deductible, or co-insurance for Aimovig. Patients with these plan limitations are not eligible for the Aimovig® Copay Card but may be eligible for other needs-based assistance provided by Amgen. These programs are often referred to as accumulator adjustment programs. If you believe your commercial insurance plan may have such limitations, please contact AimAlly at 1-833-AIMOVIG (833-246-6844).

The Aimovig® Copay Card also may provide a reduced benefit amount, unilaterally determined by Amgen in its sole discretion, to satisfy the out-of-pocket cost-sharing requirement for any patient whose plan or plan agent (including, but not limited to, a Pharmacy Benefit Manager (PBM)) requires enrollment in the Aimovig® Copay Card as a condition of the plan or PBM waiving some or all of an otherwise applicable patient out-of-pocket cost-sharing amount. These programs are often referred to as copay maximizer programs. If you believe your commercial insurance plan may have such limitations, please contact AimAlly at 1-833-AIMOVIG (833-246-6844). Health plans, specialty pharmacies, and Pharmacy Benefit Managers (individually and collectively "Plan Administrators") are prohibited from enrolling patients in the Aimovig® Copay Card. Plan Administrators are prohibited from assisting patients with enrollment in the Aimovig® Copay Card. The patient, or his/her legal representative, must personally enroll in the Aimovig Copay in order to be eligible for program benefits. If at any time a patient begins receiving prescription drug coverage under any state or government program (including but not limited to Medicare, Medicaid, TRICARE, Department of Defense, or Veteran Affairs programs), the patient will no longer be able to use this card and they must contact AimAlly at 1-833-AIMOVIG (833-246-6844) (Monday through Friday, from 8AM-9PM ET) to stop their participation in this program.

Patients may not seek reimbursement for the value received from the Aimovig® Copay Card from any third-party payers, including a flexible spending account or healthcare savings account. Participating in this program means that you are ensuring you comply with any required disclosure regarding your participation in the Aimovig® Copay Card of your insurance carrier or Pharmacy Benefit Manager. Restrictions may apply. Offer is subject to change or discontinuation without notice. This is not health insurance.

III. PROGRAM DETAILS

With the Aimovig® Copay Card, a commercially insured patient who meets eligibility criteria may pay as little as a $5 copay per month for their Aimovig monthly out-of-pocket costs.

  • For all eligible patients, the Aimovig® Copay Card offers:
    • A program benefit that covers the patient's eligible out-of-pocket prescription costs for Aimovig (copay, deductible, or co-insurance) on behalf of the patient, up to a Maximum Monthly Benefit and/or a Maximum Annual Program Benefit.
    • Aimovig patients may pay $5 out of pocket at the first fill and at every refill, and Amgen will pay on behalf of the patient the remaining eligible out-of-pocket prescription costs (up to the Patient Total Program Benefit described below; Aimovig patients are responsible for all amounts that exceed this limit).
    • The Maximum Monthly Benefit will apply every month except that the first two fills for Aimovig in each calendar year will not have a Maximum Monthly Benefit.
  • Maximum Monthly Benefit, Maximum Annual Program Benefit, and/or Patient Total Program Benefit and Benefits May Change, End, or Vary without notice.
  • The Maximum Annual Program Benefit must be applied to the Aimovig patient's out-of-pocket costs (copay, deductible, or co-insurance).
  • The Patient Total Program Benefit amounts are unilaterally determined by Amgen in its sole discretion and will not exceed the Maximum Monthly Benefit or Maximum Annual Program Benefit. The Patient Total Program Benefit may be less than the Maximum Monthly Benefit or Maximum Annual Program Benefit, depending on the terms of a patient's prescription drug plan, and may vary among individual patients covered by different plans, based on factors determined solely by Amgen, to ensure all programs funds are used for the benefit of the patient. Each patient is responsible for costs above the Patient Total Program Benefit amounts. Please ask your AimAlly representative to help you understand whether your particular insurance coverage is likely to result in your reaching the Maximum Monthly Benefit, Maximum Annual Program Benefit or your Patient Total Program Benefit amount by calling 1-833-AIMOVIG (833-246-6844) and follow the prompts.
  • Participating patients are solely responsible for updating Amgen with changes to their prescription health insurance including, but not limited to, initiation of insurance provided by the government, the addition of any coverage terms that do not apply Aimovig® Copay Card benefits to reduce a patient's out-of-pocket costs, such as accumulator adjustment benefit design or a copay maximization program. Participating patients are responsible for providing Amgen with accurate information necessary to determine program eligibility. By accepting payments from Amgen made on behalf of participating patients, participating PBMs and Plans likewise are responsible for providing Amgen with accurate information regarding patient eligibility.
  • Patients may use the card every time they fill their Aimovig prescription. Benefits reset each calendar year. Re-enrollment in the program is required at regular intervals. Patients may participate in the program as long as s/he re-enrolls as required by Amgen and s/he continues to meet all of the program's eligibility requirements during participation in the program. Patients can enroll/re-enroll by calling 1-833-AIMOVIG (833-246-6844) or by going to aimovigcopaycard.com.

We appreciate your interest in Aimovig®.

Our AimAlly Support Team can provide information on options available.

833-AIMOVIG (833-246-6844)

Monday – Friday, 8 am – 9 pm ET

You can also review our patient FAQs.

Learn More

Sign up for the AimAlly 90-Day Start Program:

a simple way to get the resources and support you need to navigate your first 3 months on Aimovig®, all in one place.

learn more at Aimovig.com

We appreciate your interest in Aimovig®.

Based on the information you provided, it appears that you are not eligible for the Aimovig® Copay Card.
If you have questions about the Aimovig Copay Card, including questions about eligibility, please call the AimAlly Support Team at:


833-AIMOVIG (833-246-6844)

Monday – Friday, 8 am – 9 pm ET

You can also review our patient FAQs.

Learn More

Sign up for the AimAlly 90-Day Start Program:

a simple way to get the resources and support you need to navigate your first 3 months on Aimovig®, all in one place.

learn more at Aimovig.com

Thank you for submitting your information.

We will review your details and contact you with any questions.



Have questions?

Still looking for answers? Don't hesitate to call our AimAlly Support Team with questions you may have at 833-AIMOVIG (833-246-6844), Monday – Friday, 8 am – 9 pm ET.

see our patient FAQs

We appreciate your interest in Aimovig®.

Based on the information you provided, it appears that you are not eligible for the Aimovig® Copay Card.
However, Amgen Safety Net Foundation may be able to help.
Please contact them at amgensafetynetfoundation.com.

Have questions?

Still looking for answers? Don't hesitate to call our AimAlly Support Team with questions you may have at 833-AIMOVIG (833-246-6844), Monday – Friday, 8 am – 9 pm ET.

see our patient FAQs


Learn More

Sign up for the AimAlly 90-Day Start Program:

a simple way to get the resources and support you need to navigate your first 3 months on Aimovig®, all in one place.

learn more at Aimovig.com

It looks like you may need help with your eligibility.
We're here to help.

Call our AimAlly Support Team to learn about available options.


833-AIMOVIG (833-246-6844)

Monday – Friday, 8 am – 9 pm ET

You can also review our patient FAQs.

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