Thank you for downloading this patient assistance document from NeedyMeds. We hope this program
will help you get the medicine you need.
REMEMBER - Send your completed application to address on the form, NOT to NeedyMeds.
Did you know that NeedyMeds has thousands of other free resources?
Here’s a look at more ways we can help you save money on medicine and healthcare costs. Each one
can be found under the “Patient Savings” tab on our website:
Diagnosis-Based Assistance — NeedyMeds lists thousands of assistance programs for almost any
health condition. If you are going through chemo treatment for cancer, there are programs that can
help with wig costs and scalp-cooling products. We also list resources for free diabetes testing
supplies, caregiver lodging support, and much more.
Free, Low Cost, and Sliding Scale Clinics This popular collection contains information on
18,000+ free, low cost, and sliding scale medical and dental clinics across the U.S. It’s a great
resource if you need affordable medical treatment and don’t know where to go.
Coupons, Rebates & More You can use the NeedyMeds website to find nearly 2,000 cost-saving
opportunities for both prescription and over-the-counter drugs and medical supplies.
Medical Transportation — Need help getting to the doctor’s office or medical facility? You may be
eligible for financial assistance if you meet certain requirements.
Finally, I want to tell you about the NeedyMeds Drug Discount Card. Thousands of people use this free,
anonymous, and easy-to-use tool to get the best price on their medications. To date, our drug discount
card has saved patients over $244,000,000. Check out the next page to learn more.
Feel free to call our toll-free helpline if you have any questions. You can reach us at 1-800-503-6897
Monday-Friday, 9am-5pm Eastern Time.
Thanks for using NeedyMeds! Please let us know if we can do anything else to help you afford the costs
of your healthcare.
Rich Sagall, MD
Richard J. Sagall, MD
President, NeedyMeds
www.needymeds.org
NeedyMeds
Find help with the cost of medicine
NeedyMeds.org
P.O. Box 219
Gloucester, MA 01931
Helpline
: 1-800-503-6897
Email: info@needymeds.org
www.needymeds.org
Form from www.needymeds.org
BIN: 020750
RX PCN: NMeds
RX GRP: PDFPDF
ID: NMNA019309901930
This is a drug discount program, not an insurance plan.
Clip the card and save
• Save up to 80% on medications*
• Use at over 65,000 pharmacies
nationwide including all major chains
• Share the card with friends and family
• Use the card as oen as needed
• Free, no fees or registration
• Never expires
• A drug isn’t covered by your insurance
• Your insurance has no drug coverage
• You have a high drug deductible
What if I have insurance?
Anyone can use the card, but it can’t be combined with state or federal insurance.
You can use the card instead of insurance if:
• You have met a low medicine cap
• The card offers a better price than your copay
• You are in the Medicare Part D donut hole
What will receive a discount?
All prescription medications are eligible for savings, including over-the-counter medicines
and medical supplies written as a prescription, as well as human-equivalent pet medications
with a prescription by a veterinarian.
You can also save up to 40% off durable medical equipment, including canes, crutches, splints,
incontinence supplies and more. You can also save on diabetic supplies such as glucose meters,
test strips, lancets and diabetic shoes. Visit www.needymeds.org/dme to learn more.
The card is not valid in combination with insurance plans, including Medicare, Medicaid or any state
or federal prescription insurance. The card can be used only if you decide not to use your
government-sponsored drug plan for your purchases.
Patient: You may use this card at any of over 65,000
participating pharmacies to save on all prescription medicines.
You cannot use this card with Medicare including part D,
Medicaid, or any other state or federal programs unless you
choose not to use your government-sponsored program. In
addition, you cannot use this card with any health insurance
program, but you can use it in place of your insurance if the
card offers a better price. For questions call 1-888-602-2978
or visit www.drugdiscountcardinfo.com.
NeedyMeds Drug Discount Card
www.needymeds.org
DRUG DISCOUNT CARD
NeedyMeds
NeedyMeds.org
To obtain a plastic drug discount card, send a self-addressed, stamped envelope to:
NeedyMeds Drug Discount Card
PO Box 219
Gloucester, MA 01931
Customer Care
1-888-602-2978
Pharmacist: Administered by Medical Security Company, LLC,
Tucson, AZ.
Pharmacy Help Desk: 1-800-404-1031.
* Average savings of 60%, with potential savings of up to 80% or more (based on 2018 national program savings data).
All prescription medications are eligible for savings.
This is a drug discount program, not an insurance plan. Discounts are available exclusively through
participating pharmacies. The range of the discounts will vary depending on the type of prescription and
the pharmacy chosen. This program does not make payments directly to pharmacies. Users are required to pay
for all prescription purchases. Cannot be used in conjunction with insurance. You may call 1-888-602-2978
with questions or concerns or to obtain further information.
©2020 AbbVie S-APP1-20A-1 January 2020
APPLICATION FOR
SKYRIZI
TM
(rizankizumab
-
rzaa)
myAbbVie Assist provides free medicine to qualifying patients. We review all applications on a case-by-case
basis. Participation in our program is free; we do not collect any fees from people seeking our assistance.
CHECKLIST FOR SUBMITTING AN APPLICATION
IF YOU ARE THE PRESCRIBER, COMPLETE PAGE 2
o SECTION 1: Prescriber Information and Shipping Preference
o SECTION 2: Patient History, Diagnosis
o SECTION 3: Prescription
o SECTION 4: Prescriber Certification and Signature
IF YOU ARE A PATIENT, COMPLETE PAGE 3. PLEASE READ PAGE 4
o SECTION 5: Patient Information
o SECTION 6: Financial and Medical Information
REQUIRED: Please include proof of income for all in household. A copy of your current federal tax return
is preferred. If you do not file taxes, alternate documents are acceptable such as W-2 form, Social Security
Statement or Pay Stubs.
o SECTION 7: Insurance Information
If you have Insurance, include front and back copies of all prescription insurance cards.
To help us determine your eligibility please also include a detailed list of prescription and medical out of
pocket expenses for the household. If you have multiple prescriptions, your pharmacy can print you a list.
o SECTION 8: Additional Permission for Program Purposes (Optional)
o SECTION 9: Patient Consent and Signature
Carefully read the HIPAA authorization, patient terms of participation and privacy notice in Section 10 on
Page 4.
Provide your consent for eligibility determination by checking the box in Section 9
Confirm your understanding of our privacy policy by providing your signature and date in Section 9.
Please keep a copy for your records.
Please do not staple documents together when mailing.
FAX OR MAIL THE COMPLETED APPLICATION AND DOCUMENTATION TO THE FOLLOWING
myAbbVie Assist
D-617927, AP5 NE
1 N. Waukegan Rd.
North Chicago, IL 60064
Phone: 1-800-222-6885
Fax: 1-866-250-2803
Upon review of a completed application, we will notify the prescriber and patient about eligibility. If approved, we
will ship the medication to the patient’s home unless otherwise indicated on the application. Prior to each
subsequent shipment, we will call the patient or prescriber to schedule the next delivery.
Please contact us at 1-800-222-6885 Monday through Friday for additional assistance.
Reset Form
For full Prescribing Information please visit www.rxabbvie.com
©2020 AbbVie Page 2 of 4 S-APP1-20A-1 January 2020
PRESCRIBER PRESCRIPTION AND CERTIFICATION
TO BE COMPLETED AND FAXED BY PRESCRIBER
APPLICATION FOR SKYRIZI
TM
(rizankizumab-rzaa)
D-617927, AP5 NE; 1 N. WAUKEGAN RD
NORTH CHICAGO, IL 60064
PHONE: 1-800-222-6885 FAX: 1-866-250-2803
1
PRESCRIBER INFORMATION ● SHIPPING PREFERENCE
Prescriber Name:
MD DO Other: Derm Other:
Office Name: Office Contact Name:
Address: City/State/Zip:
NPI or SLN: Phone: Fax:
Collaborating/Supervising MD Name and NPI Name: NPI:
Check ONLY if you prefer shipping to the Prescriber’s office
:
For additional information on how AbbVie processes your personal information, please visit www.abbvie.com/privacy.html.
2
PATIENT MEDICAL HISTORY
Patient’s Name:
__________________________________
DOB:
___________
Patient
Phone:
________________
Cellphone
Work Home
No known allergies Allergies (Please list): ___________________________________________________________________________
No other medications Other Medications (Please list): ____________________________________________________________________
PLAQUE PSORIASIS OTHER: __________________
3
RX: MUST BE COMPLETED BY A LICENSED PRESCRIBER AND FAXED DIRECTLY FROM PRESCRIBER’S OFFICE
SKYRIZI 75 mg/0.83 mL
(2 syringe kit)
CHOOSE DIRECTIONS FOR USE BELOW
QUANTITY
REFILLS
On WEEK 0 and WEEK 4: Inject 150 mg (two 75 mg
injections) SQ
(Next Dose is due on Week 16)
4 syringes (2 kits) – 112 days No Refills
EVERY 12 WEEKS: Inject 150 mg (two 75 mg injections) SQ
(Starting on Week 16)
Other: ___________________________________________
2 syringes (1 kit) – 84 days
Other: ________________
1 year supply
Other: ______
PLEASE SUBMIT PRESCRIPTIONS ACCORDING TO YOUR SPECIFIC STATE LAWS, RULES AND REGULATIONS
PRESCRIBER PLEASE SIGN AND DATE
PRESCRIBER MUST MANUALLY SIGN BELOW
RUBBER STAMPS, SIGNATURE BY OTHER OFFICE PERSONNEL
OR COMPUTER
-
GENERATED IMAGES ARE NOT ALLOWED
PRESCRIBER
SIGNATURE
X
X
D
ATE:
AND DATE:
Substitution Permitted Dispense as Written
I verify that the information provided is current, complete and accurate to the best of my knowledge. myAbbVie Assist reserves the right to request
additional information if needed and to change or discontinue the program at any time, without notice. I shall not seek reimbursement for any medication
dispensed hereunder from any government program or third party, including patient, nor will I sell, trade or distribute any such medication. I also
understand that the applicant’s acceptance into the program should not influence treatment decisions. By signing this form, I authorize the program and its
representatives to transmit this prescription form electronically, by facsimile, or by mail to a pharmacy designated by the program for the dispensing of the
medication called for herein. I understand that I may not delegate signature authority. I certify that treatment with this medication is medically necessary.
4
For full Prescribing Information please visit www.rxabbvie.com
©2020 AbbVie Page 3 of 4 S-APP1-20A-1 January 2020
PATIENT INFORMATION
TO BE COMPLETED BY PATIENT
APPLICATION FOR SKYRIZI
TM
(rizankizumab-rzaa)
D-617927, AP5 NE; 1 N. WAUKEGAN RD
NORTH CHICAGO, IL 60064
PHONE: 1-800-222-6885 FAX: 1-866-250-2803
5
PATIENT INFORMATION
Patient Name:
DOB: Sex: M F
SSN (last four digits ONLY): ǀ ǀ ǀ
If you do not have an SSN, check here
:
Mailing Address: City/State/Zip:
Shipping Address (No P.O. Box): City/State/Zip:
Preferred Phone:
Cellphone
Work Home Alternate Phone:
Cellphone
Work Home
Check the Box for
Text Messages*
Mobile Phone: _______________________________
Email address: __________________________________
* I consent to receive recurring text messages from myAbbVie Assist, including service updates and medication reminders to the above number. Message and data rates may
apply. I am not required to consent or provide my consent as a condition of receiving any goods or services. I can reply HELP for help. I can text STOP to unsubscribe any time.
6
FINANCIAL AND MEDICAL INFORMATION
Please include financial documentation for everyone in the household. A copy of your current federal tax return is preferred.
If you do not file taxes, alternate documents are acceptable such as W-2 forms, Social Security Statements and Pay Stubs.
Monthly
Household Income
$__________________
Number in Household
(including yourself)
: _________
Number in household
over 18 yrs old with income
: _________
Treating Physician Name: ________________________________ Phone: __________________ Fax: ________________
**If you have any changes to your medical information please call us at 1-800-222-6885**
7
INSURANCE INFORMATION
I have no insurance coverage – go to Section 8
INSURANCE TYPE:
Medicare
M
edicaid
Private/Commercial
Other: __________________________
Please provide insurance details below and attach a front and back copy of all insurance cards. Also include a detailed list of
prescriptions such as a Pharmacy print-out and medical expenses for the household to help us determine eligibility for our program.
MEDICAL
INSURANCE
PRESCRIPTION
INSURANCE
Insurance Company:
Insurance Company:
Insurance Co. Phone:
Insurance Co. Phone:
Policy
ID
#:
Group #:
Policy ID #: Group #:
Policyholder Name:
Relationship:
BIN #: PCN #:
Do you have secondary insurance?
Yes No Unsure
Please provide your Medicare Part A Identification #: _____________________ Value of your assets: $ _____________
Assets include checking and savings accounts, CD’s, stocks and bonds, savings bonds, mutual funds, IRAs and other investments, cash at home or anywhere
else, and the value of your life insurance policies if turned in for cash right now. Do not include your home, vehicles, burial plots, or personal possessions.
8
ADDITIONAL PERMISSION FOR PURPOSES OF THE PROGRAM (optional)
I permit myAbbVie Assist to speak with the following person about this application:
Name: _____________________________ Relationship: ________________________ Phone Number: ____________________
PATIENT CONSENT
PLEASE REVIEW HIPAA AUTHORIZATION, PATIENT TERMS OF PARTICIPATION AND PRIVACY NOTICE IN
SECTION 10 TO UNDERSTAND HOW WE USE YOUR PERSONAL INFORMATION
I acknowledge that I have provided accurate and complete information and understand the Patient Terms of Participation in Section 10.
CHECK
THE
BOX:
I understand that I am providing written instructions to the Program under the Fair Credit Reporting Act authorizing
the Program to obtain information about my credit profile from credit reporting agencies or other sources. I
authorize the Program to obtain such information solely to determine PAP eligibility.
PLEASE
SIGN
AND
DATE:
My signature below certifies that I have read, understood and agree to the release of my protected health
information pursuant to the HIPAA Authorization in Section 10.
X___________________________________________________________ X ________________________
PATIENT SIGNATURE / LEGAL REPRESENTATIVE (indicate relationship) DATE
9
For full Prescribing Information please visit www.rxabbvie.com
©2020 AbbVie Page 4 of 4 S-APP1-20A-1 January 2020
PATIENT TERMS OF PARTICIPATION AND PRIVACY NOTICE
PATIENT: PLEASE READ AND SIGN IN SECTION 9
APPLICATION FOR SKYRIZI
TM
(rizankizumab-rzaa)
D-617927, AP5 NE; 1 N. WAUKEGAN RD
NORTH CHICAGO, IL 60064
PHONE: 1-800-222-6885 FAX: 1-866-250-2803
10
HIPAA AUTHORIZATION, PATIENT TERMS OF PARTICIPATION AND PRIVACY NOTICE
HIPAA AUTHORIZATION Please provide signature in Section 9 of Enrollment Form
I authorize my healthcare providers, pharmacies, insurers, and laboratory testing facilities (my “Healthcare
Companies”) to disclose information about me, my medical condition, treatment, insurance coverage, and
payment information in relation to my use of AbbVie products, to AbbVie to enroll me in and provide me with
patient assistance and support for AbbVie products. I understand that information released under this
Authorization will no longer be protected by HIPAA. I also understand that if my Healthcare Companies use
or disclose my Personal Information for marketing purposes, they may receive financial remuneration.
I understand that I am not required to sign this Authorization and that my Healthcare Companies will not
condition my treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization.
However, I understand that if I do not sign this Authorization, I cannot take part in myAbbVie Assist (should I
qualify). This Authorization will expire in 10 years or a shorter period if required by state law, unless I cancel
it sooner by calling 1-800-222-6885 or by writing to myAbbVie Assist, D-617927, AP5 NE; 1 N. Waukegan
Rd, North Chicago, IL 60064. I understand that cancelling my Authorization will not affect any use of my
information that occurred before my request was processed.
PATIENT TERMS OF PARTICIPATION
myAbbVie Assist provides free medicine to qualifying patients. Participation in our program is free; we do not collect any fees from
people seeking our assistance. Medication assistance is dependent on your ability to meet the eligibility criteria for program as
determined by myAbbVie Assist. myAbbVie Assist does not have any obligation to provide the program services to you and is not
liable in the provision of these services. The program may be changed or discontinued without notice. You will not seek
reimbursement for any products dispensed under the program. You will notify the program if your insurance or financial situation
changes. If this application has been completed by a personal representative, the personal representative will provide a copy of this
completed application to you.
If you are a member of a Medicare plan including a Medicare Prescription Drug Plan and are qualified for program assistance, you
will: (i) be eligible to obtain the medication from the program for a calendar year term (ii) not purchase this medication under your
Medicare plan while enrolled in the program; (iii) not submit claims nor seek true out-of-pocket (TrOOP) credit for the medication
provided during your enrollment; (iv) provide written notification to your Medicare Prescription Drug Plan, if applicable, that you are
receiving your medication at no cost outside of the Medicare Part D benefit.
If you have questions, want to update your information, or terminate your enrollment, please call 1-800-222-6885 or write to us at
D-617927, AP5 NE; 1 N. Waukegan Rd, North Chicago, IL 60064.
PATIENT PRIVACY NOTICE
myAbbVie Assist will use and disclose with authorized third parties your personal information including your financial and health
information collected on this enrollment form and through participation in the program for the following purposes:
(1) To determine your eligibility for the program and to provide you with related services, including transfer to a separate private or
public payer program, reimbursement services, services to ship your medication, and other support services.
(2) To obtain information from your credit profile about your income for the sole purpose of determining eligibility for the program.
This notice serves as written instruction under the Fair Credit Reporting Act authorizing myAbbVie Assist to obtain this
information.
(3) To perform research and data analytics to develop and evaluate products, services, materials, and treatments.
(4) To administer and maintain the quality of the program, including but not limited to case review, compliance checks, audit review
and accounting purposes.
For additional information on how AbbVie processes your personal information, please visit www.abbvie.com/privacy.html.
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