VUMERITY 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 VUMERITY Copay Program.

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 VUMERITY Copay Program for as long as it is offered and you are treated with this Biogen medication, provided that you meet the eligibility criteria.

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Patient Eligibility

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

Patient Information

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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.)

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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.)

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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.

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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.



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TERMS AND CONDITIONS — VUMERITY® (diroximel fumarate):

By using the VUMERITY 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 VUMERITY Copay Program is valid ONLY for patients with commercial insurance who have a valid prescription in accordance with FDA-approved Prescribing Information. The patient must have a US prescriber and a US shipping address. 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 VUMERITY. 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 program.

The VUMERITY 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 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 VUMERITY Copay Program is not valid if the costs are eligible to be reimbursed in their entirety by private insurance or other programs.

The VUMERITY 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 VUMERITY. 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 pharmacy upon receipt of appropriate claim submission. The patient’s pharmacy will be responsible for submitting claims directly to the VUMERITY Copay Program.

All patients are responsible for appropriately reporting enrollment into the VUMERITY 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 VUMERITY 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.

Pharmacist instructions for a patient with an Eligible Third Party: Submit the claim to the primary Third Party Payer first, then submit the balance due to SS&C Health as a Secondary Payer COB [coordination of benefits] as a copay only billing using BIN 019158 with patient responsibility amount and a valid Other Coverage Code, (e.g. 8). The patient's drug assistance provided through the Copay Program will be subject to an annual cap and reimbursement will be received from SS&C Health. Valid Other Coverage Code required. For any questions regarding SS&C Health online processing, please call the Help Desk at 1-844-373-0987.

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

What is VUMERITY® (diroximel fumarate)?

  • VUMERITY is a prescription medicine used to treat people with relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease in adult
  • It is not known if VUMERITY is safe and effective in children

Important Safety Information

Do not take VUMERITY if you:

  • have had an allergic reaction (such as welts, hives, swelling of the face, lips, mouth or tongue, or difficulty breathing) to diroximel fumarate, dimethyl fumarate, or any of the ingredients in VUMERITY
  • are taking dimethyl fumarate

Before taking and while you take VUMERITY, tell your healthcare provider about all of your medical conditions, including if you:

  • have liver problems
  • have kidney problems
  • have or have had low white blood cell counts or an infection
  • are pregnant or plan to become pregnant. It is not known if VUMERITY will harm your unborn baby
    • If you become pregnant while taking VUMERITY, talk to your healthcare provider about enrolling in the BlossoMS Pregnancy Registry. You can enroll in this registry by calling 1-833-569-2635 or visiting www.blossomspregnancyregistry.com. The purpose of this registry is to monitor the health of you and your baby
  • are breastfeeding or plan to breastfeed. It is not known if VUMERITY passes into your breast milk. Talk to your healthcare provider about the best way to feed your baby while using VUMERITY

Tell your healthcare provider about all the medicines you take including prescription and over-the-counter medicines, vitamins, and herbal supplements.

What should I avoid while taking VUMERITY?

  • Do not drink alcohol at the time you take a VUMERITY dose

What are the possible side effects of VUMERITY?

VUMERITY may cause serious side effects, including:

  • allergic reaction (such as welts, hives, swelling of the face, lips, mouth or tongue, or difficulty breathing). Stop taking VUMERITY and get emergency medical help right away if you get any of these symptoms
  • PML (progressive multifocal leukoencephalopathy) a rare brain infection that usually leads to death or severe disability over a period of weeks or months. Tell your healthcare provider right away if you get any of these symptoms of PML:
    • weakness on one side of the body that gets worse
    • clumsiness in your arms or legs
    • vision problems
    • changes in thinking and memory
    • confusion
    • personality changes
  • herpes zoster infections (shingles), including central nervous system infections
  • other serious infections
  • decreases in your white blood cell count Your healthcare provider should do a blood test to check your white blood cell count before you start treatment with VUMERITY and while you are on therapy. You should have blood tests after 6 months of treatment and every 6 to 12 months after that
  • liver problems. Your healthcare provider should do blood tests to check your liver function before you start taking VUMERITY and during treatment if needed. Tell your healthcare provider right away if you get any of these symptoms of a liver problem during treatment
    • severe tiredness
    • loss of appetite
    • pain on the right side of your stomach
    • have dark or brown (tea color) urine
    • yellowing of your skin or the white part of your eyes
  • serious gastrointestinal problems, including bleeding, ulcers, blockage, and tears (perforation) of the stomach or intestines. Tell your healthcare provider right away if you have any of these symptoms during treatment:
    • stomach-area pain that does not go away
    • bright red or black stools (that look like tar)
    • severe vomiting
    • severe diarrhea
    • coughing up blood or blood clots
    • vomiting blood or your vomit looks like “coffee grounds”

The most common side effects of VUMERITY include:

  • flushing, redness, itching, or rash
  • nausea, vomiting, diarrhea, stomach pain, or indigestion
  • Flushing and stomach problems are the most common reactions, especially at the start of therapy, and may decrease over time. Taking VUMERITY with food (avoid high-fat, high-calorie meal or snack) may help reduce flushing. Call your healthcare provider if you have any of these symptoms and they bother you or do not go away. Ask your healthcare provider if taking aspirin before taking VUMERITY may reduce flushing

These are not all the possible side effects of VUMERITY. Call your healthcare provider for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. For more information go to dailymed.nlm.nih.gov.

Please see full Prescribing Information, including Patient Information.

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©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.

Indication and Important Safety Information

What is VUMERITY® (diroximel fumarate)?

VUMERITY is a prescription medicine used to treat people with relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease in adults

Important Safety Information

Do not take VUMERITY if you:

  • have had an allergic reaction (such as welts, hives, swelling of the face, lips, mouth or tongue, or difficulty breathing) to diroximel fumarate, dimethyl fumarate, or any of the ingredients in VUMERITY

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