Sign Up For a UBRELVY® Migraine Treatment Rx Savings Card

*First namePlease enter first name

*Last namePlease enter last name

*Date of birth Must be at least 18 years oldPlease enter date of birth. You must be at least 18 years old

*ZIP codePlease enter a valid ZIP code

*Gender

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Please select one of the above options

*Email addressPlease enter a valid email address

Mobile phone (Optional)Please enter a valid mobile phone number (xxx-xxx-xxxx)

*Savings Card ID numberPlease enter the 11 digit number from the U-Save Card you received from your Healthcare provider

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 if you agree

By clicking the “Accept” button below, I hereby request that my treating physicians, healthcare professionals, or other healthcare providers (collectively, my “Healthcare Providers”) disclose and transmit my protected health information to Allergan and/or its designated service providers (collectively, “Allergan”) in order for Allergan to (i) provide me, or my physician, with communications about Allergan’s savings card, if eligible, reimbursement assistance programs, drug verification, healthcare provider educator services, and adherence programs (“Program”); (ii) operate, administer, register me in and/or provide me with access to the Program’s services; (iii) identify products and services that may be of interest to me and to provide me with communications about any such products and services; and (iv) develop, evaluate and improve products, services, materials and programs related to the Program or my condition or treatment. I understand that any Healthcare Providers participating in the Program will have access to my health information as part of the Program. I request that any protected health information disclosed by my Healthcare Providers pursuant to this request is transmitted electronically to a service provider in an encrypted file as required by the purposes stated above. This request is made pursuant to 45 CFR § 164.524.

I accept.*Please check box if you agree

By providing your email address above, you agree and acknowledge that you would like to receive email communications from Allergan related to UBRELVY and the UBRELVY U-Save Card Program, including site updates, patient education, as well as other Allergan products and services. The information pertaining to you that we collect will be used in accordance with our Privacy Statement. If you later wish to stop receiving certain communications, you may unsubscribe by clicking on the link provided in future emails.

By entering your mobile phone number, you agree to receive automated marketing text messages from Allergan, an AbbVie Company, at the telephone number provided. Message frequency varies by user and message and data rates may apply. You understand that you are not required to provide your consent as a condition of purchasing goods or services. View full Program Terms, Conditions, and Eligibility Criteria.

I agree, and I certify that the information I have provided about myself is complete and accurate.*Please check box if you agree

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

Ubrelvy U-Save Card Signup

You may pay as little as $10 a month—That's just $1 per pill*