Copay coupon card

Patients residing in or receiving treatment in certain states may not be eligible.

Patients may not seek reimbursement for value received from Ori for Me including the copay card from any third-party payers. Offer subject to change or discontinuance without notice. Restrictions, including monthly maximums, may apply. This is not health insurance.

SAVINGS CARD & COVERAGE

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APPROVED USES

All fields are required unless specially noted. Email Address. ZIP Code.


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What kind of prescription insurance do you have? Please enter the RxGrp number found on your savings card.

You could get HUMIRA for as little as $5.*

Please enter the RxID number found on your savings card. I would like to receive news and updates about AbbVie and its products, clinical trials, research opportunities, programs and other information that may be of interest to me.

I am not required to sign this Authorization and my Healthcare Companies will not condition my treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization. This Authorization will expire in 10 years or a shorter period if required by state law, unless I cancel it sooner by calling If you already have your card, activate it by entering your Card ID and completing the form below. You are encouraged to report negative side effects of prescription drugs to the FDA.

Visit www. Address — Line 1.

Ortho Dermatologics Access Program

Address — Line 2. Preferred Method of Contact Phone Email. Are you enrolled in any government, state or federally funded medical or prescription benefit program, including but not limited to Medicare, Medicaid, VA, DOD and Tricare? Do you have commercial insurance coverage?