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^® (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 commercially insured patients may pay as little as $10 for a 10 pack of UBRELVY. Check with your pharmacist for your out-of-pocket cost. Patient out-of-pocket expenses may vary.
4. This offer is valid for up to 12 prescription fills, but may vary based on your insurance coverage. 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.