Is the online application right for you?

Our online application is for use by the person seeking HUMIRA® (adalimumab) assistance (the patient). We will ask you to confirm your identity and agree that you have truthfully provided the information requested. We will ask you to electronically sign the application before submitting it. Before you start, please make sure that you have electronic copies of the necessary documents (listed further below).

While you can apply online, we will also need the health care provider who has prescribed your HUMIRA® (adalimumab) to submit application documents separately. To complete the online application, you can type your information directly in the portal and then upload your supporting documentation. Once you have submitted your application, we will contact your health care provider to obtain your HUMIRA® (adalimumab) prescription and other needed information.

Our online form will guide you through the steps needed to complete your application:

We will contact your prescribing doctor for the remaining information. We also will notify you and your health care provider after we have reviewed your application. If you are approved for assistance, we will provide refills based on the prescription from your health care provider.

What documents must be electronically available?

  1. Income documents: Your Federal Tax Return for the most current filing year is the preferred income document. If you do not have a tax return, we will accept copies of your pay stub (for at least two pay periods), social security statement, social security disability statement, W-2 form, or 1099-R form.
  2. Insurance and Expense Information: If you have insurance, you will need to provide the following documents:
    1. Prescription or medical insurance card – a front and back copy of the card is needed.
    2. List of the prescription medications from your pharmacy. If a pharmacy printout is not available, please include a medication list.
    3. Medical expenses for everyone in the household.

Click here for an optional expense form that can be used to document your prescription and medical expenses.

What if I am not the patient OR I do not have all of my documents available electronically?

If you need help at any point during this process, please call us at 1-800-222-6885 Option #4 Monday through Friday 7:00 am to 7:00 pm CST

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Call us at 1-800-222-6885 Option #4 Monday through Friday from 7:00 am to 7:00 pm Central Time.