TYSABRI Copay Program

Eligible commercially insured patients may lower their out-of-pocket costs to as low as $0.

During participation in the program, assistance provided by Biogen will not exceed an individual annual cap, which is based on certain factors, including but not limited to, insurance coverage, claim details, and/or participation in other insurance plan-sponsored programs. Once this cap is reached, you will be responsible for paying 100% of your total copay amount. By completing this form, you will be screened for eligibility in the TYSABRI Copay and/or Administration Copay Program(s).

Federal and state laws and other factors may prevent or otherwise restrict eligibility. People covered by Medicare, Medicaid, Veterans Affairs (VA), the Department of Defense (DoD), or any other federal plans are not eligible to enroll. You are eligible to enroll in the TYSABRI Copay and/or Administration Copay Program(s) for as long as it is offered and you are treated with TYSABRI, provided that you meet the eligibility criteria.

;

Patient Eligibility

  • 1
  • 2
  • 3
  • 4

Please answer all questions and click "SUBMIT" to continue.

Please provide State.

*TRICARE® is a registered trademark of the Department of Defense; Defense Health Agency. All rights reserved.

Patient Information

  • 1
  • 2
  • 3
  • 4

Please answer all questions and click "SUBMIT" to continue.

Please provide First Name.
Please provide Last Name.
Please provide Date of Birth.
Please provide Gender.
Please provide Address.
Please provide City.
Please provide State.
Please provide Zip Code.
Please provide Patient Home Phone Number.
Please provide Patient Cell Phone Number.
Please provide email address.
Please select a response.

Your registration is almost finished!

  • 1
  • 2
  • 3
  • 4

In order to allow Biogen to provide you with support services,
please complete the patient authorization below.

I. Authorization to Share Health Information

I understand that I have certain rights related to the collection, use, and disclosure of [my/my child’s] medical and health information. This information is called “protected health information” (PHI) and includes demographic information (such as sex, race, date of birth, etc.), the results of physical examinations, clinical tests, blood tests, X-rays, and other diagnostic medical procedures that may be included in [my/my child’s] medical records. Biogen will not use [my/my child’s] PHI without my consent.

By signing this Authorization, I authorize [my/my child’s] healthcare provider, [my/my child’s] health insurance company and [my/my child’s] pharmacy providers (“Healthcare Entities”) to disclose to Biogen, and companies working with Biogen (collectively, “Biogen”), health information relating to [my/my child’s] medical condition, treatment, and insurance coverage for Biogen to (i) provide [me/my child] with support services (and related information and materials) related to any of Biogen’s products, including but not limited to, online support, financial assistance services, compliance and persistency and other therapy support services, and (ii) conduct data analysis, market research and other necessary internal business activities, and (iii) provide me with information about Biogen’s products, services, and programs for educational or other purposes. I understand that once I sign this Authorization, and [my/my child’s] medical and health information is disclosed to Biogen by the Healthcare Entities, the Health Insurance Portability and Accountability Act (HIPAA) will no longer protect my information because Biogen is not covered by HIPAA. However, Biogen agrees to protect [my/my child’s] health information by using and disclosing it only for purposes authorized in this Authorization or as required by law or regulations. I understand that [my/my child’s] pharmacy provider may receive remuneration from Biogen in exchange for the health information and/or for any therapy support services provided to [me/my child].

I understand that I may refuse to sign this Authorization. I further understand that [my/my child’s] treatment (including with a Biogen product), payment for treatment, insurance enrollment or eligibility for insurance benefits are not conditioned upon my agreement to sign this Authorization; but if I do not sign it or later cancel it, [I/my child] will not be able to receive Biogen’s therapy support services.

I may cancel this Authorization at any time by mailing a letter to: Biogen, ATTN: Patient Services, 5000 Davis Drive, Morrisville, NC, 27560 or emailing privacy@biogen.com. Canceling this Authorization will end consent to further disclosure of [my/my child’s] health information to Biogen by [my/my child’s] Healthcare Entities after they are notified of my cancellation but will not affect previous disclosures by them pursuant to this Authorization. Canceling this authorization will not affect [my/my child’s] ability to receive treatment, payment for treatment, or [my/my child’s] eligibility for health insurance.

This Authorization expires ten (10) years, or such shorter timeframe required by applicable law, from the day I sign it as indicated by the date next to my signature unless otherwise canceled earlier as set forth above.

I have read and understand the Authorization to Share Health Information and agree to the terms.

Please type your name below to provide your signature to authorize the consent:
(If the patient is a minor and you are the patient's Parent/Legal Guardian, please type in your name.)

Enter first name.
Enter last name.
First and last name do not match what was entered in the Patient Information section.

II. Patient Services Authorization

By signing this Authorization, I authorize Biogen, and companies working with Biogen, to provide [me/my child] with support services related to any of Biogen’s products, including but not limited to: online support, financial assistance services, compliance and persistency and other therapy support services, as well as any information or materials related to such services. I understand and agree that personnel, including but not limited to nurses, providing such support services on behalf of Biogen are not employed by [my/my child’s] healthcare professional. I authorize Biogen, and companies working with Biogen, to contact me to provide such services and information by mail, email, fax, telephone call, text message (including calls and text messages made with an automatic telephone dialing system or a prerecorded voice), chat, push notifications and other forms of electronic messaging.

I also authorize Biogen, and companies working with Biogen, to use and disclose [my/my child’s] medical and health information in connection with providing the services, including but not limited to, disclosing [my/my child’s] information to vendors, processors, and service providers for business purposes associated with providing the services, sharing such information with [my/my child’s] healthcare provider, insurance provider, or pharmacy, or disclosing [my/my child’s] information where required by applicable laws or regulations. I also authorize the disclosure of [my/my child’s] health information to specific individuals that I have designated.

I have read and understand the Patient Services Authorization and agree to the terms

Please type your name below to provide your signature to authorize the consent:
(If the patient is a minor and you are the patient's Parent/Legal Guardian, please type in your name.)

Enter first name.
Enter last name.
First and last name do not match what was entered in the Patient Information section.

III. Marketing Authorization

By checking the “Agree to terms” box, I authorize Biogen, and companies working with Biogen, to contact me by mobile or online digital media, mail, email, fax, telephone call, and text message (including autodialed and prerecorded calls and messages) for marketing purposes or otherwise provide me with information about Biogen’s products, services, and programs or other topics of interest, conduct market research or otherwise ask me about [my/my child’s] experience with or thoughts about such topics. I understand and agree that any information that I provide may be used by Biogen for marketing, including targeted online marketing, as well as to develop new products, services, and programs. I understand that Biogen will not sell or transfer [my/my child’s] personal data to any unrelated third party for marketing purposes without my express permission. I understand that my consent is not required as a condition of purchasing or receiving any goods or services from Biogen. I understand that I may revoke this authorization and choose not to receive information from Biogen by sending an email with the subject “Unsubscribe” to privacy@biogen.com, or mailing a letter to Biogen, 5000 Davis Drive, Morrisville, NC 27560. For more information visit biogen.com/privacy.

Make selection.
  • Home Phone : 
  • Mobile Phone : 
  • Email : 

Residents of certain US States (including but not limited to California) may have additional rights regarding the collection, use, maintenance, disclosure, and deletion of your personal information. To understand or exercise those rights California residents please visit https://www.biogen.com/privacy-center.html.

I understand that I have the right to receive a copy of the terms and conditions of my agreement with Biogen, and that I may request that copy at the time of signing or at a later date by contacting Biogen at: Biogen, ATTN: Patient Services, 5000 Davis Drive, Morrisville, NC, 27560 or emailing privacy@biogen.com.



Please choose an option to receive your one-time verification code that you need to enter later to complete the enrollment.

Make selection.

TERMS AND CONDITIONS — TYSABRI® (natalizumab):

By using the TYSABRI Drug Copay Program and/or the TYSABRI Administration Copay Program, the patient acknowledges and confirms that, at the time of usage, they are currently eligible and meet the criteria set forth in the terms and conditions described below.

The TYSABRI Drug Program and/or the TYSABRI Administration Copay Program is/are valid ONLY for patients with commercial insurance who have a valid prescription in accordance with the FDA-approved Prescribing Information and with the Medication Guide provided to the patient at the time of administration. The patient must have a US prescriber and a US shipping address or administration site. The patient must be a US resident or US citizen. If the patient has federally-funded insurance, such as Medicare, Medicaid, VA, TRICARE®*, or DoD insurance coverage, the patient is not eligible for assistance through the Biogen Copay Program for TYSABRI. If the patient obtains a federally-funded plan, such as Medicare, Medicaid, VA, TRICARE, or DoD, at any time during the enrollment period, the patient must notify Biogen immediately, and Biogen may be required to stop copay payments and immediately remove patient from the TYSABRI Drug Copay Program and/or the TYSABRI Administration Copay Program.

The TYSABRI Drug Copay Program covers only the cost of the drug and does not cover copays related to administration, office visits, or any network penalties levied by patient’s insurance. The drug assistance provided through the Copay Program will be subject to an annual cap. Once the maximum amount of assistance has been provided, the patient will be responsible for paying 100% of total copay amounts for the remainder of the year after funds are exhausted.

The TYSABRI Administration Copay Program only covers costs associated with the administration of TYSABRI. The assistance provided will not exceed $250 per administration or $3,250 per year. Once the maximum amount of assistance has been provided, the patient will be responsible for paying 100% of total copay and procedure amounts for the remainder of the year after funds are exhausted.

The TYSABRI Drug Copay Program and/or the TYSABRI Administration Copay Program is/are not valid if the costs are eligible to be reimbursed in their entirety by private insurance or other programs. The TYSABRI Administration Copay Program is not offered to patients who are residents of Massachusetts or Rhode Island or receive treatment in Massachusetts or Rhode Island.

The TYSABRI Drug Copay Program and/or the TYSABRI Administration Copay Program cap will reset every January 1st. These programs are not health insurance or benefit plans. The programs do not obligate the use of a specific product or provider.

The Copay Program is intended to help patients afford TYSABRI. Patients may have insurance plans that attempt to increase the amount of patient’s out-of-pocket costs to reflect the availability of support offered by a manufacturer assistance program. In those situations, the program may change its terms including but not limited to removing these patients from the program.

Biogen will not provide copay assistance directly to the patient. All program claims will be paid directly to the patient’s administration site or pharmacy upon receipt of appropriate claim submission. The patient’s pharmacy or administration site will be responsible for submitting claims directly to the TYSABRI Drug Copay Program and/or the TYSABRI Administration Copay Program.

All patients are responsible for appropriately reporting enrollment into the TYSABRI Drug Copay Program and/or the TYSABRI Administration Copay Program as required by their insurer. It is the patient’s responsibility to ensure compliance with all terms of their insurance as outlined by their insurance plan.

Eighteen (18) months of inactivity may result in removal from the TYSABRI Drug Copay Program and/or the TYSABRI Administration Copay Program.

Biogen reserves the right to modify or discontinue this program with respect to any patient, or in its entirety, at any time. Patient participation does not mean that the patient is entitled to receive assistance indefinitely.

*TRICARE is a registered trademark of the Department of Defense; Defense Health Agency. All rights reserved.

What is TYSABRI® (natalizumab)?

TYSABRI® (natalizumab) is a prescription medicine used to treat relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease. TYSABRI increases the risk of progressive multifocal leukoencephalopathy (PML). When starting and continuing treatment with TYSABRI, it is important to discuss with your doctor whether the expected benefit of TYSABRI is enough to outweigh this risk.

It is not known if TYSABRI is safe and effective in children under 18 years of age.

IMPORTANT SAFETY INFORMATION

What is the most important information I should know about TYSABRI?

TYSABRI increases your risk of getting a rare brain infection—called progressive multifocal leukoencephalopathy (PML)—that usually leads to death or severe disability.

  • There is no known treatment, prevention, or cure for PML
  • You should not take certain medicines that weaken your immune system at the same time you are taking TYSABRI. Even if you use TYSABRI alone to treat your MS, you can still get PML
  • Your risk of getting PML is higher if you:
    • have been infected by the John Cunningham Virus (JCV). JCV is a common virus that can cause PML in people who have weakened immune systems, such as people taking TYSABRI. Before or while you receive TYSABRI, your doctor may do a blood test to check if you have been infected by JCV
    • have received TYSABRI for a long time, especially for longer than 2 years
    • have received certain medicines that can weaken your immune system before you start receiving TYSABRI
  • Your risk of getting PML is greatest if you have all 3 risk factors listed above. There may be other risk factors that have not yet been identified
  • Patients who are anti-JCV antibody negative are still at risk for the development of PML due to the potential for a new JCV infection or a false negative test result. Therefore, patients with a negative test result should be retested periodically
  • While you receive TYSABRI, and for 6 months after you stop receiving TYSABRI, it is important that you call your doctor right away if you have any new or worsening medical problems (such as problems with your thinking, eyesight, balance, or strength; weakness on 1 side of your body; and using your arms and legs) that have lasted several days. Tell all of your doctors that you are getting treatment with TYSABRI
  • Because of your risk of getting PML while you receive TYSABRI, TYSABRI is available only through a restricted distribution program called the TOUCH® Prescribing Program

Who should not receive TYSABRI?

Do not receive TYSABRI if you have PML or are allergic to natalizumab or any of the ingredients in TYSABRI.

What should I tell my doctor before receiving each dose of TYSABRI?

Before receiving TYSABRI, it is important to tell your doctor:

  • If you have a medical condition that can weaken your immune system, such as HIV infection or AIDS, leukemia or lymphoma, organ transplant, or others, or if you have any new or worsening medical problems that have lasted several days
  • If you are pregnant or plan to become pregnant. TYSABRI may cause low platelets, and in some cases also low red blood cells (anemia), in your newborn baby if you take TYSABRI while you are pregnant. It is not known if TYSABRI can cause birth defects
  • If you are breastfeeding or plan to breastfeed. TYSABRI can pass into your breast milk. It is not known if TYSABRI that passes into your breast milk can harm your baby. Talk to your doctor about the best way to feed your baby while you receive TYSABRI
  • About all of the medicines and supplements you take, especially medicines that can weaken your immune system. If you are not sure, ask your doctor

What are the possible side effects of TYSABRI?

TYSABRI can cause serious side effects. If you have any of the symptoms listed below, call your doctor right away:

  • Herpes infections. Increased risk of infection of the brain or the covering of your brain and spinal cord (encephalitis or meningitis) caused by herpes viruses that may lead to death. Symptoms include sudden fever, severe headache, or confusion. Infection of the eye caused by herpes viruses leading to blindness in some patients has occurred. Call your doctor if you have changes in vision, redness, or eye pain
  • Liver damage. Symptoms include yellowing of the skin and eyes (jaundice), unusual darkening of the urine, nausea, feeling tired or weak, or vomiting
  • Allergic reactions (e.g., hives, itching, trouble breathing, chest pain, dizziness, wheezing, chills, rash, nausea, flushing of skin, low blood pressure), including serious allergic reactions (e.g., anaphylaxis). Serious allergic reactions usually happen within 2 hours of the start of the infusion, but they can happen any time after receiving TYSABRI
  • Weakened immune system. TYSABRI may increase your risk of getting an unusual or serious infection
  • Low platelet counts. TYSABRI may cause the number of platelets in your blood to be reduced. Symptoms include easy bruising, small scattered spots on your skin that are red, pink or purple, heavier menstrual periods than are normal, bleeding from your gums or nose that is new or takes longer than usual to stop, or bleeding from a cut that is hard to stop

The most common side effects of TYSABRI are:

  • Headache, feeling tired, urinary tract infection, joint pain, lung infection, depression, pain in your arms or legs, diarrhea, vaginitis, rash, nose and throat infections, nausea, stomach area pain. If you experience any side effect that bothers you or does not go away, tell your doctor

These are not all of the possible side effects of TYSABRI. For more information, ask your doctor. To report side effects to FDA, please call 1-800-FDA-1088.

Please see full Prescribing Information, including Boxed Warning and Medication Guide.

This information does not take the place of talking with your healthcare provider about your medical condition or your treatment.

©2026 Biogen. All rights reserved. 04/25 FPS-US-0272 v6

This site is intended for residents 18 years or older of the United States, Puerto Rico, and US territories.

All trademarks are the property of their respective owners.

Biogen Logo

©2026 Biogen. All rights reserved. 04/25 FPS-US-0273 v6

This site is intended for residents 18 years or older of the United States, Puerto Rico, and US territories.

All trademarks are the property of their respective owners.

IMPORTANT SAFETY INFORMATION AND INDICATION

What is TYSABRI® (natalizumab)?

TYSABRI® (natalizumab) is a prescription medicine used to treat relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease. TYSABRI increases the risk of progressive multifocal leukoencephalopathy (PML). When starting and continuing treatment with TYSABRI, it is important to discuss with your doctor whether the expected benefit of TYSABRI is enough to outweigh this risk.

{"crx-wl-channel":"web","surveyDescription":"Survey1","surveyName":"Survey1","resolveEnrollmentSearchFields":{"patient.firstName":{},"patient.lastName":{},"patient.gender":{},"patient.dob":{},"patient.postalCode":{}},"verifyOtp":true,"maxResendLimit":"3","otpCommunicationType":"both","otpEnrollmentStatus":"rejected","otpValidTime":"15","otpValidUnit":"minutes","emailCommunication":{"emailTemplateId":"Biogen_OTPTemplate","emailAssetId":"8aba3099-9b3b-e911-80c8-005056a96666.html","emailFrom":"no-reply@connectiverx.com","emailTo":"","emailSubject":"Biogen Copay Program Temporary Verification Code","emailFormFields":[{"Id":"OTP","Font":null,"FontSize":null,"Text":"000000"}]},"smsCommunication":{"application":"000000"}}