Ubrelvy U-Save Card Signup-new

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[Hidden] Origin Name

Step 1 of 2

Please answer the following questions:

*Required

Do you already have a UBRELVY Complete Savings Card?*

Yes

[Hidden]Campaign Master ID

Do you live in either the United States or Puerto Rico?*

Yes

Do you have commercial prescription drug insurance? (If you have Medicaid, Medicare, or other government-sponsored prescription insurance, such as VA/DOD, select “No.”)*

Yes

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Step 2 of 2

*Required

*First name

*Last name

*Date of birth Must be at least 18 years old

*ZIP code

*Gender

Female

Male

Email Address missing or SourceId invalid in the request object

Email Does not Exist

Email is Invalid

Email Validation failed or Domain Correction.

*Email address

Your email will be used only to provide assistance with this program.

Mobile phone (Optional)

Your phone number will be used only to provide assistance with this program.

Card number not recognized

*Savings Card ID number

Your phone number will be used only to provide assistance with this program.

Card number Already Activated

SavingsCard Response ID [Hidden]

I consent to receive UBRELVY automated and recurring text messages from “AbbVie”, including services updates, medication reminders and marketing messages to the above mobile number. Message and data rates may apply. I am not required to consent as a condition of receiving goods or services. I can reply HELP for help. I can reply STOP to opt out at any time. View Privacy Notice and Mobile Terms & Conditions here.

By activating your UBRELVY® Savings Offer, you certify that you are not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare, Medicaid, or any private indemnity or HMO insurance plan that reimburses you for the entire cost of your prescription drugs. You also certify that you are not Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. You further certify that should you begin receiving prescription benefits from one of these types of programs at any time, you will no longer participate in this savings program.

I agree to this certification, and I have read and accept the Program Terms, Conditions, and Eligibility Criteria.

Please check box below if you would like to receive email communications from AbbVie related to UBRELVY and the UBRELVY Complete Savings Card Program, including site updates, patient education, as well as other AbbVie products and services.

I consent to the collection, use, and disclosure of my health-related personal data and/or precise geolocation personal data to receive communications from AbbVie regarding its products, programs, services, clinical trials, research opportunities and for online targeted advertising, as further described in the “How we may use Personal Data,” “How we disclose Personal Data,” and “Cookies and similar tracking and data collection technologies” sections of our Privacy Notice. My consent is required to process sensitive personal data under certain privacy laws, and I have the right to withdraw my consent by visiting “Your Privacy Choices” on AbbVie's website.

Privacy Notice: AbbVie may collect your personal data through your online and offline interactions with us, including your contact data, geolocation and health-related data...

...We may also collect your online usage data automatically through cookies and similar technologies. We use this information for several purposes, such as to provide you with, administer, and improve our programs, services and products, customize your experiences, and for research and analytics. We retain your personal data for as long as necessary to fulfill these purposes or to comply with our record retention obligations. We do not sell your personal data, but may use and disclose your personal data with marketing and advertising partners to deliver you ads based on your interests inferred from your activity across other unaffiliated sites and services (“online targeted advertising”) and for website analytics. To opt out of the use or disclosure of your personal data for online targeted advertising or for website analytics, go to Your Privacy Choices on our website. For more information on the personal data categories we collect, the purposes for their collection, disclosures to third parties, and data retention, visit our Privacy Notice.

Through my submission of the Registration Form, I consent to the collection, use, and disclosure of my personal health data, as described in the Privacy Notice above and in AbbVie’s Privacy Notice in the “How We May Disclose Personal Data” section. My consent is required to process sensitive personal data under certain privacy laws, and I have the right to withdraw my consent by visiting “Your Privacy Choices” on AbbVie’s website.

If you have any questions about the UBRELVY Complete Savings Card, please call 1.844.4.UBRELVY (1.844.482.7358), Monday–Friday, 8:00 am to 8:00 pm Eastern Time.

Source Id

ResponseID

NOW ELIGIBLE PATIENTS * MAY PAY AS LOW AS $0

FOR UBRELVY—THAT MAY MEAN NO COST TO YOU

Step 2 of 2

The Savings Card ID number you entered is no longer valid. Don't worry - it's easy to get a new UBRELVY Complete Savings Card. Just click the button below to access your savings

The savings card ID number you entered was not valid. Don't worry though, it's easy to get a new UBRELVY Complete Savings Card. Click "Get new card" now to access savings. If you want to try to re-enter your number click "Go back."

Please provide appropriate value in each field's default value property as per Analytics Tech Specs

Form Name:

Form Category:

Account Management, Contact, Interactions, Quiz, Registration, Services

Form Sub-Category:

Password Resets, Login, Profile, Representative, Contact Us, Polls, Social Share, Doctor Discussion Guide, Dosing Guide, Symptom Checker, Knowledge Assessment, Event, More Info, Sign Up, Saving Card, Benefit Verification, Benefit Enrollments, Medical Exception, Injection Form, Share a Story

Form MVA Name:

Form MVA Type:

Download, Form, Link, Share, Tool, Video

Form MVA Tier:

Form MVA Category:

Savings Card, Insurance, Symptom Journal, Test Score Tracker, Condition Information, Doctor Discussion Guide, Dosing Information, Enrollment Form, Flashcard, Medical Exception, Patient Counseling Guide, Savings Card, Symptom Journal, Doctor Discussion Guide, Doctor Search, Dosage Calculator, Enroll, Med Reminders, Quick Poll, Resource Request, Symptom Quiz, UGC Submission, Contact Rep, Savings Card, Social Share, App Store, More Info, Patient Resources, Share Information, Share Results, Submit a Story, Assessment Tool, Benefits Verification, Carousel, Initiation, Myth versus Fact, Workaround Quiz, Formulary Tool, Image Expand, Medical Exception, Q And A, Slider, Administration Instructions, Condition Information, Insurance, Inventory, Mechanism of Action, Patient Story, Product Overview, Program Overview, Injection Training, Other

Form PII Field Names for Masking:

Form Analytics Payload:

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