![]() ![]() I understand that any Healthcare Providers participating in the Program will have access to my health information as part of the Program. I am electronically providing my signature indicating that I hereby authorize and request that my treating physicians, healthcare professionals, or other healthcare providers (collectively, my "Healthcare Providers") disclose and transmit my protected health information in electronic form to Biohaven and/or its designated service providers (collectively, "Biohaven") in order for Biohaven to (i) provide me, or my physician, with communications about benefits verification, my insurance plan's coverage status of prescribed Biohaven medications, Biohaven's patient affordability programs, healthcare provider educator services, and adherence programs ("Program") (ii) operate, administer, register or enroll me in and/or provide me with access or continue access to the Program's services (iii) identify products and services that may be of interest to me and to provide me with communications about any such products and services and (iv) develop, evaluate and improve products, services, materials and programs related to the Program or my condition or treatment. If you had previously provided your consent for Biohaven to use your protected health information, you can opt out here. This Program is managed by ConnectiveRx on behalf of Biohaven Pharmaceuticals. Biohaven Pharmaceuticals reserves the right to rescind, revoke or amend this offer without notice anytime. This Program is void if copied, transferred, purchased, altered, or traded and where prohibited by law. Valid only for patients 18 years and older in the United States including the Commonwealth of Puerto Rico. This offer may not be used with any other financial assistance program, free trial, discount, prescription savings card or other offer. Continued eligibility may require that the patient has a prior authorization form submitted. ![]() Patients with managed care restrictions (e.g., prior authorization, step edit) may not be eligible for this offer if such managed care restrictions persist. ![]() This Program is not valid for prescriptions covered by or submitted for reimbursement in part or in full by any state or federally funded programs, including but not limited to Medicare, Medicaid, Medigap, VA, TRICARE (DOD). Restrictions: This offer is not valid for Non‑Insured/Cash‑Paying Patients. Patients with questions about the Program should call 1‑800‑761‑1568. Eligible patients with commercial insurance may pay as little as $0 out of pocket. To the Patient: In order to participate in the Nurtec ODT Patient Savings Program ("Program"), you must have a valid prescription for Nurtec® ODT (rimegepant) orally disintegrating tablets, meet the eligibility requirements set forth herein, adhere to the terms and conditions stated in the Restrictions section below, and present the copay card to your pharmacist. ![]()
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