<h1>Ubrelvy Email Signup</h1><h2>Learn about a different way to treat migraine</h2>Sign up to receive more information about UBRELVY&reg;&mdash; a different way to treat your migraine attacks.<img title="Sign up for UBRELVY emails" alt="Email Icon" data-src="https://www.datocms-assets.com/16555/1578587993-email-green-resize.svg" /><img title="Sign up for UBRELVY emails" alt="Email Icon" data-src="https://www.datocms-assets.com/16555/1578588001-email-dark-resize.svg" class="migraine-mode-img right-0" />

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Learn About UBRELVY® (ubrogepant) Email Sign-up

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I authorize Allergan and its contractors and business partners (&ldquo;Allergan&rdquo;) to use and/or disclose my personal information, including my personal health information, for the following purposes: (1) to operate, administer, enroll me in, and/or continue my participation in the UBRELVY U-Save Program and/or any other Allergan-affiliated patient support services and activities related to my condition or treatment (for example, co-pay card programs if eligible, reimbursement assistance programs, drug coverage verification, health care provider educator services, adherence programs, and disease management support); (2) to contact my doctor and the rest of my health care providers and share with them my health information that may be useful for my care; (3) to provide me with informational and promotional materials relating to Allergan products and services, and/or my condition or treatment; and/or (4) to improve, develop, evaluate, and continue Allergan products, services, materials, and programs related to my condition or treatment.In order for Allergan to provide the above services and programs to me, I understand that Allergan will need my personal information and my health information, which may include my name, address, email address, information about my health condition, my treatment and product information, treatment dates, eligible treatment type, my medical history and general health, my health care plan benefits and coverage, information about my adherence to my treatment, and other relevant personal and health information (&ldquo;Personal Health Information&rdquo;). I authorize my health care providers, including my doctor&rsquo;s office, pharmacies, health plans, laboratory services, and other health care providers, and all employees, individuals, and entities working with or for such health care providers (&ldquo;Health Care Providers&rdquo;) who have my Personal Health Information to release and disclose my Personal Health Information to Allergan only for the purposes set forth above, including providing me with the UBRELVY U-Save Program.I understand that some of my Health Care Providers (such as pharmacies and specialty pharmacies) may receive remuneration from Allergan in exchange for disclosing my Personal Health Information and/or for using my information to contact me with communications about Allergan products that have been prescribed to me and other patient support services.My Health Care Providers may release my Personal Health Information in whatever form and through whatever media, including the internet, as required by the purposes set forth.I further understand that once my Health Care Providers disclose my Personal Health Information to Allergan, it may no longer be covered by federal privacy regulations, and, therefore, could be re-disclosed. However, Allergan agrees to protect my Personal Health Information by only using and disclosing it as stated in this Authorization or as otherwise allowed or required by law.I understand that I may receive a copy of this authorization or revoke this authorization at any time by calling ______________ or writing to [list appropriate AGN contact]. However, if I revoke this authorization, I understand I may no longer qualify for the UBRELVY U-Save Program and/or the other services described above. I further understand that if a Health Care Provider is disclosing my Personal Health Information to Allergan, my revocation of this authorization will only prevent further disclosure of my Personal Health Information to Allergan by such Health Care Providers after they receive notice of my revocation.I understand that this authorization is voluntary and I may refuse to sign it. My refusal to sign will not affect my ability to obtain treatment or payment for my treatment. But, I may be ineligible to qualify for the UBRELVY U-Save Program and the other programs and services set forth above.I understand that this authorization for my Health Care Providers to disclose my Personal Health Information will not expire unless I notify Allergan to terminate it, or unless another date is specified herein, or is required by state or other applicable law(s).Electronic Authorization:I understand that by clicking the &ldquo;I accept&rdquo; button below, that I am consenting electronically and providing legal authorization for Allergan, including any affiliates, subcontractors, and/or agents of Allergan (such as vendors operating the UBRELVY U-Save Program to use and share, and for my Health Care Providers to disclose, my Personal Health Information for the purposes described within the above authorization. I am also indicating that I am at least 18 years old and either the patient or legal guardian of the patient by clicking the &ldquo;I accept&rdquo; button.

Authorization for use and release of protected health information Ubrelvy U-Save Program

1. This offer is valid only for patients 18 years of age or older and is good for use only with a valid prescription for UBRELVY&reg; (ubrogepant) tablets at the time the prescription is filled by the pharmacist and dispensed to the patient.2. This offer is not valid for use by patients enrolled in Medicare, Medicaid, or other federal or state programs (including any state pharmaceutical assistance programs), or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this card if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. This offer is not valid for cash-paying patients.3. Depending on your insurance coverage, most eligible patients may pay as little as $10. Check with your pharmacist for your copay discount. Patient out-of-pocket expense may vary.4. This offer is valid for up to 12 prescription fills, but may vary based on your insurance coverage.&nbsp; Offer applies only to prescriptions filled before the program expires on December 31, 2021.5. AbbVie reserves the right to rescind, revoke, or amend this offer without notice.6. Offer good only in the USA, including Puerto Rico, at participating retail pharmacies.7. Void if prohibited by law, taxed, or restricted.8. This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law.9. This card has no cash value and may not be used in combination with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription.10. This offer is not health insurance.11. This card expires December 31, 2021.12. By redeeming this card, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer.For questions about the program, including savings on mail-order prescriptions, or to activate your card ID, please call 1-844-577-6239.Pharmacist Instructions for a Patient with an Eligible Third-Party Payer: When you redeem this card, you certify that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government programs for this prescription. Submit the claim to the primary Third-Party Payer first, then submit the balance due to CHANGE HEALTHCARE using BIN# 600426 as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code (eg, 8). If you receive a rejection due to PA, or NDC block, submit Other Coverage Code of 03 (secondary claim). Patients pay as little as $10. Reimbursement will be received from CHANGE HEALTHCARE. For any questions regarding CHANGE HEALTHCARE online processing, call the UBRELVY Claims Concierge at 1-800-761-5285. Program managed by ConnectiveRx on behalf of AbbVie.

By clicking &ldquo;Yes&rdquo; below, you acknowledge and agree that Allergan does not, in any way, endorse or recommend the qualifications of any physician associated with the third-party website, or the quality of medical care any of those physicians can provide. Allergan makes no guarantees that using the third-party website will result in your desired outcome. It is wholly and solely your responsibility to assess the qualifications of a potential physician. Allergan recommends that you meet and discuss the benefits and risks of all potential treatments with the potential physician. ALLERGAN AND ITS RESPECTIVE AFFILIATES HEREBY DISCLAIM ANY LIABILITY ARISING FROM YOUR USE AND/OR RELIANCE ON THE INFORMATION CONTAINED ON THE THIRD-PARTY WEBSITE.If you agree to the above, click &ldquo;YES&rdquo; to proceed to the third-party website. If you do not agree to the above, click &ldquo;NO&rdquo; to remain on UBRELVY.com.

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Did You Hear? Serena Williams Partners with UBRELVYUBRELVY is proud to partner with world tennis champion Serena Williams, who is living with migraine. Serena needs a migraine treatment that she can take anytime, anywhere.

If you&rsquo;re unable to access your own provider or don&rsquo;t have one, you can talk to a doctor today from the comfort of your own home. Get access to a third-party healthcare professional online who can help find the right migraine treatment plan for you!

<h2>Talk to a Healthcare Provider Today</h2>

IMPORTANT SAFETY INFORMATION Who should not take UBRELVY&reg; (ubrogepant)? Do not take UBRELVY if you are taking medicines known as strong CYP3A4 inhibitors, such as ketoconazole, clarithromycin, itraconazole.What should I tell my healthcare provider before taking UBRELVY? Tell your healthcare provider about all your medical conditions, including if you:<ul><li>Have liver problems</li><li>Have kidney problems</li><li>Are pregnant or plan to become pregnant</li><li>Are breastfeeding or plan to breastfeed</li></ul>Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Your healthcare provider can tell you if it is safe to take UBRELVY with other medicines.What are the most common side effects of UBRELVY? The most common side effects are nausea (4%) and sleepiness (3%). These are not all of the possible side effects of UBRELVY.What is UBRELVY? UBRELVY is a prescription medicine used for the acute treatment of migraine attacks with or without aura in adults. UBRELVY is not used to prevent migraine headaches.Please see full <a href="https://media.allergan.com/products/Ubrelvy_pi.pdf#page=14" title="Prescribing" target="_blank" rel="noopener">Patient Information.</a>

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