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Once your healthcare provider prescribes BIMZELX^® (bimekizumab-bkzx) for you, you can access personalized tools for your treatment plan, connect with a Nurse Navigator,* manage savings, and find injection training resources–all in one place.

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I have a prescription or am treating with BIMZELX.

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I agree to receive communications from UCB's BIMZELX Navigate^® Program (the "Program"), including but not limited to autodialed, prerecorded and/or artificial voice calls and autodialed text messages, at the phone number(s) I provided to offer enrollment support, insurance coverage and financial assistance resources and support, injection resources and support, treatment reminders, resources and support, and for other non-marketing, patient support purposes. If I have designated a personal representative, I certify that he or she also agrees hereby to receive such voice and text communications, including through an autodialer or prerecorded voice, from the Program for the purposes described above at the phone number(s) provided.

For text messages, message and data rates may apply. I understand that I may receive up to two (2) text messages per month. For questions, contact the BIMZELX Navigate Nurse Navigator* at 1-833-931-6877. View the complete Terms of Use.

I understand that I (and my personal representative, if applicable) may opt out of receiving text messages from the Program at any time by replying "STOP"; and for voice and text message communications by (1) sending an email to PrivacyOptOut@ucb.com, or (2) mailing a letter to UCBCares at 1950 Lake Park Drive, Smyrna, GA 30080, stating that I wish to opt out of receiving communications from UCB in connection with BIMZELX Navigate and including my First Name, Last Name, Date of Birth, ZIP Code, and gender (as assigned at birth) for reference.

Patient Authorization to Use/Disclose Health Information. Please read and sign the form in order to create your account.

By signing this Patient Authorization to Use/Disclose Health Information ("Authorization"), I hereby authorize each of my physicians, pharmacists (including any specialty pharmacy that receives my prescription for a UCB medication), and other of my healthcare providers (together, "Providers") and each of my health insurers (together, "Insurers") to disclose information related to my medical condition and treatment (including prescription information), my health insurance coverage and policy number, my name, mailing and email addresses, telephone number, and date of birth (together, "Health Information"), to UCB, Inc. and its agents, service providers, contractors, and representatives (together, "UCB"). My Health Information will be shared with UCB so that UCB may: (i) enroll me in, and contact me about, patient support programs and/or related market research for UCB medications; (ii) provide me with educational materials and information related to UCB medications; (iii) verify, investigate, assist with, and coordinate my coverage for a UCB medication with my Insurers and Providers; (iv) determine my eligibility for and help me access savings, interim care and/or free drug programs for UCB medications; (v) conduct market research and/or analyses or other commercial activity, including aggregating my Health Information with other data for such analyses; (vi) assist with analysis related to quality, efficacy, and safety for UCB medications; (vii) de-identify my Health Information for use for any purpose under applicable law.

I understand that once my Protected Health Information has been disclosed to UCB, federal privacy laws may no longer protect the information and it may be subject to re-disclosure. However, I understand that UCB and other parties authorized to receive my health information pursuant to this Authorization agree 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 one or more Provider and/or Insurer may receive payment from UCB for disclosing my Health Information for some or all of the purposes listed above.

I understand that I do not have to sign this Authorization and choosing not to sign will not affect my ability to receive treatment from my Providers or payment from my Insurers. However, if I do not sign this form, UCB may not be able to provide me with certain patient support. Once my Health Information has been disclosed to UCB, I understand that federal privacy laws may no longer protect this information. However, I understand that UCB and other parties authorized to receive my Health Information pursuant to this Authorization agree 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 also understand that one or more Providers and/or Insurers may receive payment from UCB for disclosing my Health Information for some or all of the purposes listed above.

I understand I am not required to sign this Authorization, and that if I decline to sign, it will not affect my treatment (including the receipt of UCB medication), payment for treatment, insurance enrollment, or eligibility for insurance benefits, but it may mean that I will not receive the other services described above.

I understand that this Authorization is voluntary and that I am not required to sign this Authorization. I may revoke this Authorization at any time (1) by mailing a letter, including my First Name, Last Name, Date of Birth, Gender, and ZIP Code, requesting such cancellation to UCBCares^® at 1950 Lake Park Drive, Smyrna, GA 30080; or (2) by informing my Providers in writing that I do not want them to share any information with UCB.

I understand that revoking my Authorization means my physicians, pharmacies, and health plans, as well as UCB, Inc., may no longer rely on the Authorization to use or disclose my Health Information, but it will not affect previous disclosures made by them pursuant to this Authorization. UCB shall provide timely notification of my revocation of this Authorization to my Providers and Insurers. Once my Providers and Insurers receive and process the notice of revocation of this Authorization, my Providers and Insurers may no longer make disclosures of my Health Information to UCB as permitted by this Authorization. This Authorization expires 10 years from the date it was signed unless a shorter period is mandated by the law of my state of residence, or unless otherwise revoked as outlined above. I understand that I have the right to receive a copy of this Authorization once it is signed.

Type your first and last name below to sign this form and acknowledge you have read and agree to the terms of the Authorization to Use/Disclose Health Information for patient support services for BIMZELX. By doing so and clicking "Confirm," you agree that your electronic signature is valid and an equivalent of your manual or handwritten signature.

*Nurse Navigators do not provide medical advice and will refer you to your healthcare professional for any treatment-related questions.

Based on your answer, you are not eligible for a MyNavigate portal account.

IMPORTANT SAFETY INFORMATION:

BIMZELX is a medicine that affects your immune system and may increase your risk of serious side effects, including suicidal thoughts and behavior, serious infections including tuberculosis, liver problems, and inflammatory bowel disease.

BIMZELX^® is a prescription medicine used to treat adults with moderate-to-severe plaque psoriasis who may benefit from taking injections or pills (systemic therapy) or treatment using ultraviolet light alone or with pills (phototherapy).

IMPORTANT SAFETY INFORMATION

What is the most important information I should know about BIMZELX^® (bimekizumab-bkzx)?

BIMZELX is a medicine that affects your immune system. BIMZELX may increase your risk of having serious side effects, including:

Suicidal thoughts and behavior have happened in some people treated with BIMZELX. Get medical help right away or call the National Suicide and Crisis Lifeline at 988 if you, your caregiver or your family member notice in you any of the following symptoms:
- new or worsening depression or anxiety
- thoughts of suicide, dying, or hurting yourself
- changes in behavior or mood
- acting on dangerous impulses
- attempt to commit suicide
Infections. BIMZELX is a medicine that may lower the ability of your immune system to fight infections and may increase your risk of infections, including serious infections.
- Your healthcare provider should check you for infections and tuberculosis (TB) before starting treatment with BIMZELX.
- If your healthcare provider feels you are at risk for TB, you may be treated with medicine for TB before you begin treatment with BIMZELX and during your treatment.
- Your doctor should watch you closely for signs and symptoms of TB during and after treatment with BIMZELX. Do not take BIMZELX if you have an active TB infection.

Before starting BIMZELX, tell your healthcare provider if you:

are being treated for an infection
have an infection that does not go away or that keeps coming back
have TB or have been in close contact with someone with TB
think you have an infection or have symptoms of an infection such as:
- fever, sweats, or chills
- muscle aches
- cough
- shortness of breath
- blood in your phlegm
- weight loss
- warm, red, or painful skin or sores on your body different from your psoriasis
- diarrhea or stomach pain
- burning when you urinate or urinating more often than normal

After starting BIMZELX, call your healthcare provider right away if you have any of the signs of infection listed above. Do not use BIMZELX if you have any signs of infection unless you are instructed to by your healthcare provider. See “What are the possible side effects of BIMZELX?” for more information about side effects.

What is BIMZELX?

BIMZELX is a prescription medicine used to treat:

adults with moderate-to-severe plaque psoriasis who may benefit from taking injections or pills (systemic therapy) or treatment using ultraviolet light alone or with pills (phototherapy)
adults with active psoriatic arthritis
adults with active non-radiographic axial spondyloarthritis with objective signs of inflammation
adults with active ankylosing spondylitis
adults with moderate-to-severe hidradenitis suppurativa.

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

Before using BIMZELX, tell your healthcare provider about all of your medical conditions, including if you:

have any of the conditions or symptoms listed in the section “What is the most important information I should know about BIMZELX?”
have a history of depression, or suicidal thoughts or behavior
have liver problems
have inflammatory bowel disease (Crohn’s disease or ulcerative colitis)
have recently received or are scheduled to receive an immunization (vaccine). You should avoid receiving live vaccines during treatment with BIMZELX.
are pregnant or plan to become pregnant. It is not known if BIMZELX can harm your unborn baby.
- If you become pregnant while taking BIMZELX, you are encouraged to enroll in the Pregnancy Registry, which is used to collect information about the health of you and your baby. Talk to your healthcare provider or call 1-877-311-8972 to enroll in this registry or visit http://mothertobaby.org/pregnancy-studies/.
are breastfeeding or plan to breastfeed. It is not known if BIMZELX passes into your breast milk. Talk to your healthcare provider about the best way to feed your baby during treatment with BIMZELX.

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 BIMZELX?

BIMZELX may cause serious side effects. See “What is the most important information I should know about BIMZELX?”

Elevated liver enzyme levels. Your healthcare provider will do blood tests to check your liver enzyme levels before starting treatment and during treatment with BIMZELX. Your healthcare provider may temporarily stop or permanently stop your treatment with BIMZELX if you develop liver problems. Call your healthcare provider right away if you develop any signs or symptoms of liver problems, including:
- pain on the right side of your stomach-area
- feeling very tired
- loss of appetite
- nausea and vomiting
- itching
- dark urine
- light-colored stool
- yellowing of your skin or the whites of your eyes
Inflammatory bowel disease. New cases of inflammatory bowel disease or “flare-ups” have happened with BIMZELX. If you have inflammatory bowel disease (Crohn’s disease or ulcerative colitis), tell your healthcare provider if you have worsening disease symptoms during treatment with BIMZELX or develop new or worsening signs of Crohn’s disease or ulcerative colitis.

The most common side effects of BIMZELX in people treated for psoriasis and moderate-to-severe hidradenitis suppurativa include: upper respiratory tract infections, headache, herpes simplex infections (cold sores in or around the mouth), small red bumps on your skin, feeling tired, fungal infections (oral thrush or infection in the mouth, throat, skin, nails, feet, or genitals), pain, redness or swelling at injection site, stomach flu (gastroenteritis), and acne.

The most common side effects of BIMZELX in people treated for psoriatic arthritis include: upper respiratory tract infections, headache, urinary tract infections, oral thrush or infections in the mouth, and diarrhea.

The most common side effects of BIMZELX in people treated for non-radiographic axial spondyloarthritis include: upper respiratory tract infections, headache, cough, joint pain, tonsillitis, urinary tract infections, oral thrush or infections in the mouth, diarrhea, feeling tired, muscle aches, and an increase in liver enzyme levels.

The most common side effects of BIMZELX in people treated for ankylosing spondylitis include: upper respiratory tract infections, headache, pain at injection site, vaginal yeast infections, oral thrush or infections in the mouth, diarrhea, and rash.

These are not all of the possible side effects of BIMZELX. Call your doctor for medical advice about side effects.

Use BIMZELX exactly as your doctor tells you to use it.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-10881-800-FDA-1088.

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