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

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 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 medical records. Biogen will not use my PHI without my consent.

By signing this Authorization, I authorize my healthcare provider, my health insurance company and my pharmacy providers ("Healthcare Entities") to disclose to Biogen, and companies working with Biogen (collectively, "Biogen"), health information relating to my medical condition, treatment, and insurance coverage for Biogen to (i) provide me 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 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 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 pharmacy provider may receive remuneration from Biogen in exchange for the health information and/or for any therapy support services provided to me.

I understand that I may refuse to sign this Authorization. I further understand that my 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 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, PO Box 13919, Research Triangle Park, NC, 27709 or emailing privacy@biogen.com. Canceling this Authorization will end my consent to further disclosure of my health information to Biogen by my 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 ability to receive treatment, payment for treatment, or my 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 I 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 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 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 medical and health information in connection with providing the services, including but not limited to, disclosing my information to vendors, processors, and service providers for business purposes associated with providing the services, sharing such information with my healthcare provider, insurance provider, or pharmacy, or disclosing my information where required by applicable laws or regulations. I also authorize the disclosure of my health information to specific individuals that I have designated.

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

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III. Marketing Authorization

By selecting YES to this Authorization, I authorize Biogen, and companies working with Biogen, to contact me by mail, email, fax, telephone call, and text message 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 experience with or thoughts about such topics. I understand that Biogen may use auto-dialers, prerecorded messages and artificial voice messages to contact me at the telephone number I have provided on this form and that my mobile provider may charge me to receive these messages. I understand and agree that any information that I provide may be used by Biogen for marketing purposes, including targeted online marketing, as well as to help develop new products, services, and programs. I understand that Biogen will not sell or transfer my personal information to any unrelated third party for marketing purposes without my express permission. I understand that my consent to receive marketing communications 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 services or information from Biogen by mailing a letter to the address above or sending an email with the subject "Unsubscribe" to privacy@biogen.com.

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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/california-policy.html. For more information, 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, PO Box 13919, Research Triangle Park, NC, 27709 or emailing privacy@biogen.com.



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Avonex Web Card
BIN#
PCN#
GRP#
ID#

Please provide the copay card information (BIN, PCN, GRP, and ID) to your specialty pharmacy to ensure that your benefit is processed in a timely manner.

TERMS AND CONDITIONS — AVONEX® (interferon beta-1a):

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

The AVONEX 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 AVONEX. 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 AVONEX Copay Program.

All patients are responsible for appropriately reporting enrollment into the AVONEX 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 AVONEX 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 AVONEX® (interferon beta-1a)?:

AVONEX 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 in adults.

It is not known if AVONEX is safe and effective in children.

Important Safety Information

Who should not use AVONEX?

  • Do not take AVONEX if you are allergic to interferon beta or any of the ingredients in AVONEX

Before beginning treatment, you should discuss with your healthcare provider the potential benefits and risks associated with AVONEX.

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

AVONEX can cause serious side effects. Tell your healthcare provider right away if you have any of the symptoms listed below while taking AVONEX.

  • Depression, suicidal thoughts, hallucinations or other behavioral health problems. Some people taking AVONEX may develop mood or behavior problems, including irritability (getting upset easily), depression (feeling hopeless or feeling bad about yourself), nervousness, anxiety, aggressive behavior, thoughts of hurting yourself or suicide, and hearing or seeing things that others do not hear or see (hallucinations)

If you have any of these mood or behavior problems, your healthcare provider may tell you to stop taking AVONEX.

  • Liver problems, or worsening of liver problems including liver failure and death. Tell your healthcare provider right away if you have any of these symptoms: Nausea, loss of appetite, tiredness, dark colored urine and pale stools, yellowing of your skin or the white part of your eye, bleeding more easily than normal, confusion, and sleepiness. During your treatment with AVONEX you will need to see your healthcare provider regularly and have regular blood tests to check for side effects. Tell your healthcare provider about all the medicines you take and if you drink alcohol before you start taking AVONEX
  • Serious allergic reactions and skin reactions. Serious allergic and skin reactions can happen when you take AVONEX. Symptoms of serious allergic and skin reactions may include itching, swelling of the face, eyes, lips, tongue or throat, trouble breathing, anxiousness, feeling faint, and skin rash, hives, sores in your mouth, or your skin blisters and peels

Get emergency help right away if you have any of these symptoms. Talk to your healthcare provider before taking another dose of AVONEX.

Before taking AVONEX, tell your healthcare provider about all of your medical conditions, including if you:

  • are being treated for a mental illness, or had treatment in the past for any mental illness, including depression and suicidal behavior
  • have or had bleeding problems or blood clots, have or had low blood cell counts, have or had liver problems, have or had seizures (epilepsy), have or had heart problems, have or had thyroid problems, have or had any kind of autoimmune disease (where the body’s immune system attacks the body’s own cells)
  • drink alcohol
  • have or have had an allergic reaction to rubber or latex. The tip cap of the AVONEX prefilled syringe and prefilled autoinjector Pen contain natural rubber latex
  • are pregnant or plan to become pregnant. It is not known if AVONEX can harm your unborn baby
  • are breastfeeding or plan to breastfeed. AVONEX may pass into your breastmilk. Talk with your healthcare provider about the best way to feed your baby if you take AVONEX

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

What are the possible side effects of AVONEX?

AVONEX can cause serious side effects, including:

  • Injection site reactions. AVONEX may cause redness, pain, itching, or swelling at the place where your injection was given. Call your healthcare provider right away if an injection site becomes swollen and painful or the area looks infected. You may have a skin infection or an area of severe skin damage (necrosis) requiring treatment by a healthcare provider
  • Heart problems, including heart failure. Some people who did not have a history of heart problems developed heart muscle problems or congestive heart failure after taking AVONEX. If you already have heart failure, AVONEX may cause your heart failure to get worse. Call your healthcare provider right away if you have worsening symptoms of heart failure such as shortness of breath or swelling of your lower legs or feet while using AVONEX
    • Some people using AVONEX may have other heart problems including low blood pressure, fast or abnormal heartbeat, chest pain, and heart attack or a heart muscle problem (cardiomyopathy)
  • Blood problems. AVONEX can affect your bone marrow and cause low red and white blood cell, and platelet counts. In some people, these blood cell counts may fall to dangerously low levels. If your blood cell counts become very low, you can get infections and problems with bleeding and bruising
  • Thrombotic microangiopathy (TMA). TMA is a condition that involves injury to the smallest blood vessels in your body. TMA can also cause injury to your red blood cells (the cells that carry oxygen to your organs and tissues) and your platelets (cells that help your blood clot) and can sometimes lead to death. Your healthcare provider may tell you to stop taking AVONEX if you develop TMA
  • Pulmonary arterial hypertension. Pulmonary arterial hypertension can occur with interferon beta products, including AVONEX. Symptoms may include new or increasing fatigue or shortness of breath. Contact your healthcare provider right away if you develop these symptoms
  • Seizures. Some people have had seizures while taking AVONEX, including people who have never had seizures before. Tell your healthcare provider right away if you have a seizure
  • Autoimmune diseases. Problems with easy bleeding or bruising (idiopathic thrombocytopenia), thyroid gland problems (hyperthyroidism and hypothyroidism), and autoimmune hepatitis have happened in some people who use AVONEX

The most common side effects of AVONEX include:

  • Flu-like symptoms. Most people who take AVONEX have flu-like symptoms especially early during the course of therapy. Usually, these symptoms last for a day after the injection. Symptoms may include muscle aches, fever, tiredness, and chills

You may be able to manage these flu-like symptoms by taking over-the-counter pain and fever reducers. Talk with your healthcare provider about ways to help if you develop flu-like symptoms while taking AVONEX.

These are not all of the possible side effects of AVONEX.

Call your healthcare provider for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Please see full Prescribing Information and Medication Guide.

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

INDICATION AND IMPORTANT SAFETY INFORMATION

What is AVONEX® (interferon beta-1a)

AVONEX 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 in adults.

Important Safety Information

Who should not use AVONEX?

  • Do not take AVONEX if you are allergic to interferon beta or any of the ingredients in AVONEX

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