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

Enroll to Get Your Card

Please provide the information below to enroll in your Access Card and participate in Aimovig Ally support programs.

Required information*

Please enter your first name
Please enter your last name
Please select your sex
Select your month
Select your day
Select your year.
Must be 18 years or older
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 3 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 Novartis Pharmaceuticals Corporation and Amgen Inc., its affiliates, business partners, and agents (“Novartis and 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 Novartis and Amgen products, disease education and awareness and management programs, and promotional materials related to my condition or treatment;
(v) manage the Aimovig Ally support program;
(vi) If I am eligible, coordinate the Aimovig Ally Access 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 Aimovig Ally support program and other related programs.

I give permission to Novartis and 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 Novartis and Amgen in exchange for disclosing my personal information to Novartis and 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 2355, Morristown, NJ 07962. I also understand that if a Healthcare Provider or Insurer is disclosing my personal information to Novartis and Amgen on an authorized, ongoing basis, my cancellation with Novartis and 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 Aimovig Ally support program and related programs. If I revoke this authorization, Novartis and 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 Aimovig Ally support program may change or end at any time without prior notification.

I agree to be contacted by Novartis and 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 Novartis and 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 Novartis and 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 Novartis and Amgen do 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
Confirm Your Eligibility

The following questions are to be answered by the patient:
What type of insurance do you use to pay for your Aimovig® prescription at the pharmacy?

?
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?*

By checking this box, I agree that I read, understand, and accept the Terms and Conditions Terms and Conditions of the Aimovig Ally Access Card.*

You must agree to Terms and Conditions to enroll

We appreciate your interest in Aimovig® (erenumab-aooe).

Based on the information you provided, it appears that you are not eligible for the Aimovig Ally Access Card.

Should you feel you are eligible for the program, please list your commercial prescription insurance information to aid in our review. We will review your details and contact you with any questions.

You may still receive the Aimovig Ally patient support resources that you previously selected. If you'd prefer NOT to receive them, please click here.

Thank you. You have been opted out of all Aimovig Ally support resources.

Have questions?

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

see our patient FAQs

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 Aimovig Ally Care Center 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® (erenumab-aooe).

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

You may still receive the Aimovig Ally patient support resources that you previously selected. If you'd prefer NOT to receive them, please click here.

Thank you. You have been opted out of all Aimovig Ally support resources.

Have questions?

Still looking for answers? Don't hesitate to call our Aimovig Ally Care Center 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® (erenumab-aooe).

Our Aimovig Ally Care Center can provide information on options available.



Have questions?

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

see our patient FAQs
{"crx-wl-channel":"web","crx-wl-survey-description":"Amgen Aimovig hub channel patient survey responses.","crx-wl-survey-name":"Aimovig Patient Survey v1.0.0","groupNumber":"EC12705001","reEnrollGroupList":"EC12705001,EC12705002,EC12705003,EC12705004,EC12705013","hubGroupList":"EC12705002,EC12705013","enrollGroup":"EC12705001","activationGroup":"EC12705003","mobileGroup":"EC12705004","reenrollStatus":"expired","byPassAddressValidation":false,"client":"amgen","brand":"aimovig","brandPath":"aimovig","view":"enroll"}