Select RQ Indication

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Rheumatoid Arthritis (RA)

Psoriatic Arthritis (PsA)

Ankylosing Spondylitis (AS)

Atopic Dermatitis (AD)

Ulcerative Colitis (UC)

Nonradiographic Axial Spondylitis (nr-axSpA)

Crohn’s Disease (CD)

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Information for the Patient:

The patient attests that he or she is NOT receiving prescription drug coverage under any federal, state or government-funded insurance program. The patient further understands that if at any time he or she begins receiving prescription drug coverage under any federal, state or government-funded prescription insurance program, he or she will no longer be able to use the program.
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IMPORTANT INFORMATION: By submitting this form, you are referring the above patient to AbbVie’s patient support program to determine eligibility and receive support related to an AbbVie product. Please share this information with your patient.

Copay Program

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