When you sign up for an account, you get access to submit online applications, the ability to sign those applications electonically and to submit supporting documents.

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.

If you have already created an account, click here to login.

1 Basic Information
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You will use your email address to log into your account.
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2 Insurance Information
We need to collect the following to determine eligibility into our program. This information will not be used for any purposes other than verifying your financial coverage.

Once the application is filled out and signed, please upload these supplemental documents:

  • Front and back of your insurance card

  • Detailed list of medical expenses for household, including medications, office visits, insurance premiums, medical bills, etc.

  • Complete the Patient Authorization for Disclosure of Information section

Refer to the Out of Pocket Expense Form here

Primary Insurance

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Add Secondary Insurance (Optional) Remove Secondary Insurance

Secondary Insurance

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3 Account Information
Your password must be 8 to 16 characters long and include at least three of the following: uppercase letter, lowercase letter, number, symbol [such as @, #, $].
4 Authorization for Disclosure

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Help 1-800-222-6885

DO YOU HAVE ANY QUESTIONS?

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