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

Re-Enroll Your Card

Please provide the information below to re-enroll your Copay Card and participate in AimAlly support programs. The Aimovig® Copay Card Program is ongoing, and in order to remain eligible, patients must re-enroll at regular intervals.

Required information*

Please enter your copay card group number
?
If you do not know your Aimovig® Copay Card group number, please call Aimovig at 833-AIMOVIG (833-246-6844), Monday – Friday, 8 am – 9 pm ET.
Please enter your copay card member ID
?
If you do not know your Aimovig® Copay Card member ID, please call Aimovig at 833-AIMOVIG (833-246-6844), Monday – Friday, 8 am – 9 pm ET.
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

As a next step, please read and provide your responses below to the Patient Authorization and consent(s).

Step 1 of

*Please make a selection

Authorization for Use and Disclosure of Protected Health Information

Uses and disclosure of Protected Health Information

I authorize Amgen and its data processors (collectively, “Amgen”) to collect, use, and disclose my protected health information for the following purposes:

  • To operate, administer, enroll me in, and/or continue my participation in Amgen’s AimAlly program or any other Amgen-affiliated patient support services and activities related to my condition or treatment (for example, co-pay card programs, reimbursement assistance programs, drug coverage verification, nurse educator services, adherence program and disease management support);
  • To contact, with my permission, my doctor and the rest of my health care team and share with them my health information that may be useful for my care;
  • To provide me with informational and promotional materials relating to Amgen products and services, and/or my condition or treatment; and/or
  • To improve, develop, and evaluate Amgen’s products, services, materials and programs related to my condition or treatment.

In order for Amgen to provide me with the services and/or programs described above, Amgen needs to collect and use my personal information, including my protected health information. I understand that my protected health information may include any information, in electronic or physical form, in the possession of or derived from a health care provider, health care plan, pharmacy, pharmaceutical company, laboratory and/or their contractor (each, a “Health Care Provider”). This may include select information from or about my medical history and general health, my health care plan benefits, payment limits or restrictions covered by my health care plan policy, and/or my adherence to my treatment.

I authorize my Health Care Providers to disclose my protected health information to Amgen, and between themselves, as necessary, but only for the purposes stated above in this Authorization. I understand that certain of my Health Care Providers (such as pharmacies and specialty pharmacies) may receive remuneration from Amgen in exchange for disclosing my protected health information and/or for using my information to contact me with communications about Amgen products which have been prescribed to me (for example, medication reminder programs and other patient support services).

Expiration, Right to Obtain a Copy, and Right to Cancel
I understand that by signing this form, I authorize my Health Care Providers or others who might hold my health information to disclose it to Amgen. I also understand I am authorizing my personal information, including my protected health information, to be used for the purposes described above. I understand and agree that by signing below, I am authorizing those who rely on this Authorization to disclose my protected health information for the earlier of five (5) years or until my participation in Amgen’s AimAlly ends through my cancellation, unless a shorter time period is required by state law.

I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by calling Amgen at 1-833-246-6844 or by writing to PO Box 2205 Morristown, NJ 07962. If I cancel this Authorization, I will no longer qualify for the services described. I also understand that if a Health Care Provider is disclosing my protected health information to Amgen in reliance on this Authorization on an on-going basis, my cancellation with Amgen will be effective with respect to any such Health Care Providers as soon as they receive notice of my cancellation.

No Effect on Treatment
I understand I do not have to sign this Authorization and that my enrollment in any of the services and/or programs described above is entirely voluntary. I understand that Amgen, as well as Health Care Providers, cannot require me, as a condition of having access to medications, prescription drugs, treatment or other care, to sign this Authorization. Federal Law (including HIPAA) requires a signed authorization in order for Amgen to collect my protected health information from my Health Care Providers. I understand I cannot participate in the listed services and/or programs without signing this Authorization or an equivalent authorization with my Health Care Providers.

Information Received from Health Care Providers
I understand that once my protected health information has been disclosed to Amgen, federal privacy laws may no longer apply and may no longer protect it from further disclosure, and that Amgen may disclose my protect health information to its data processors, contractors, and business partners for its business purposes. Amgen agrees, however, to protect my protected health information by only using and disclosing it as stated in the Authorization or as otherwise allowed or required by law.

By clicking the “I accept” button, I am electronically indicating that I have read and understood the above Authorization for Use and Disclosure of Protected Health Information (above in its full text), that I am legally authorized to consent, and that I am providing my consent as the patient or the patient’s legal representative for Amgen to collect, use, and disclose my protected health information for the purposes described within this Authorization. By clicking “Cancel” below, my activation and enrollment into AimAlly will be discontinued.

By selecting "I do not accept," you will not be able to continue enrolling in AimAlly

Step 2 of

*Please make a selection

I consent to Amgen processing my Health Data for the following purposes:

  • To enroll me and manage my participation in Amgen’s AimAlly program, which includes activities related to my condition or treatment (for example, co-pay card programs, payer medication coverage verification, nurse educator support, disease management support), and to manage Amgen’s products, services, and programs related to my condition or treatment.

Amgen uses the following when it administers the AimAlly program:

  • Health Data – my name (and the name of my caregiver if applicable), gender, date of birth, contact information and information relating to my health condition or treatment.

I understand that my consent to processing is required for me to participate in the AimAlly program. I also understand that Amgen will not sell my Health Data to third parties, but Amgen may disclose my Health Data to Amgen’s data processors, contractors, and business partners for Amgen’s business purposes related to the AimAlly program. I understand that Amgen may use my Health Data to contact me by mail, email, or telephone for the above purposes. I also understand that if I do not consent to the use of my Health Data for the above purposes, I will not be able to participate in the AimAlly program. Finally, I understand that I may withdraw my consent to processing my Health Data for the above purposes at any time using one of the methods listed in the Additional Disclosures section below and that if I withdraw my consent, I will no longer be able to participate in the AimAlly program.

By selecting "I do not consent to the collection, processing, or disclosure of my Health Data for the above purposes," you will not be able to continue enrolling in AimAlly

Step 3 of

*Please make a selection

I consent to Amgen collecting and processing my Health Data for the following purposes:

  • To conduct marketing activities, including market research activities, and to communicate with me regarding products and services that may be of interest to me.

Amgen uses the following for marketing purposes:

  • Health Data – my name, gender, date of birth, contact information and information relating to my health condition or treatment.

I understand that Amgen is seeking my consent to collect and process my Health Data to market products and services to me and that I do not have to give consent to the collection and processing of my Health Data for marketing purposes in order to participate in the AimAlly program. I also understand that Amgen will not sell my Health Data to third parties. If I consent to the collection and processing of my Health Data for marketing purposes, I agree that Amgen may contact me for marketing purposes. Finally, I understand that I may withdraw my consent to the collection and processing of my Health Data for marketing purposes at any time using one of the methods listed in the Additional Disclosures section below.

Step 4 of

*Please make a selection

I consent to Amgen disclosing my Health Data to its data processors, contractors, and business partners for the following purposes:

  • To conduct marketing activities, including market research activities, and to communicate with me regarding products and services that may be of interest to me.

Amgen discloses the following for such purposes:

  • Health Data – my name, gender, date of birth, contact information and information relating to my health condition or treatment.

I understand that Amgen is seeking my consent to disclose my Health Data to its data processors, contractors, and business partners to market products and services to me and that I do not have to give consent to disclosure of my Health Data for marketing purposes in order to participate in AimAlly. I also understand that Amgen will not sell my Health Data to third parties. Finally, I understand that I may withdraw my consent to the disclosure of my Health Data for marketing purposes at any time using one of the methods listed in the Additional Disclosures section below.

If you do not consent to the disclosure of your health data for marketing purposes, you will not be able to receive marketing communications from Amgen. If you want to receive marketing communications from Amgen, select "I consent to the diclosure of my Health Data for marketing purposes"

Additional Disclosures

I understand that participation in the AimAlly program and, if I have consented, receipt of marketing communications are optional services at no cost to me. The consent(s) above in no way affects my right to obtain any medications and I do not have to provide consent to be able to receive any medications. To obtain a copy of the consent(s) above or to withdraw my consent to collection, processing, and/or disclosure of my Health Data for any of the above purposes to which I have consented, I can contact Amgen by visiting www.amgen.com/DataSubjectRights or calling 833-AIMOVIG (833-246-6844). For more information about Amgen’s privacy practices, Amgen’s Privacy Statement can be found at http://www.amgen.com/privacy.

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.

Looks like you're enrolling too soon. Your re-enrollment opportunity begins 60 days prior to your expiration date.
If you have any questions or need further assistance, simply call our AimAlly Support Team at:

833-AIMOVIG (833-246-6844)
Monday – Friday, 8 am – 9 pm ET.

Learn More

Find additional Aimovig® resources, like a daily text migraine tracker, supplemental injection support, and more.

learn more at Aimovig.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

Find additional Aimovig® resources, like a daily text migraine tracker, supplemental injection support, and more.

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

Find additional Aimovig® resources, like a daily text migraine tracker, supplemental injection support, and more.

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

Find additional Aimovig® resources, like a daily text migraine tracker, supplemental injection support, and more.

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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