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Rhonda

DUPIXENT MyWay® Patient Ambassador,
on DUPIXENT
Individual results may vary.
"They are a very good source of information and support. ... I really feel like they are advocating for me.”

What Can DUPIXENT MyWay® Do for You?

Fill out this form to see if you are eligible for the DUPIXENT MyWay Copay Card. You will get the latest information about DUPIXENT, exclusive tools and resources to help you understand and manage your condition.

You are not eligible to register for a new copay card or to activate a copay card. However, if you have not already done so, you can join our email list to receive support from DUPIXENT MyWay. Just submit this form.

I am enrolling in the DUPIXENT MyWay Program (the "Program") and authorize Regeneron Pharmaceuticals, Inc., Sanofi US, and their agents (together the "Alliance") to provide me services under the program, and as may be added in the future. Such services include medication and adherence communications and support, medication dispensing support, coverage and financial assistance support, disease and medication education, injection training and other support services (the "Services").

I agree to my enrollment in the DUPIXENT MyWay Copay Card program if confirmed as eligible, understand that copay card information will be sent to my designated specialty pharmacy/in-network specialty pharmacy along with my prescription, and any assistance with my applicable cost-sharing or co-payment for DUPIXENT (dupilumab) will be made in accordance with the Program terms and conditions.

I authorize the Alliance to contact me by mail, telephone, or email, with information about the Program, moderate-to-severe eczema (atopic dermatitis) and products, promotions, services and research studies, and to ask my opinion about such information and topics, including market research and disease-related surveys.

I further authorize the Alliance to de-identify my health information and use it in performing research, education, business analytics, marketing studies or for other commercial purposes. I understand that members of the Alliance may share identifiable health information with one another in order to de-identify it for these purposes and as needed to perform the Services or to send the communications listed above (the "Communications"). I understand and agree that the Alliance may use my health information for these purposes and may share my health information with my doctors, specialty pharmacies, and insurers.

I understand that I do not have to enroll in the Program or receive the Communications, and that I can still receive DUPIXENT, as prescribed by my physician. I may opt out of receiving Communications, individual support services offered by the Program, including the DUPIXENT MyWay Copay Card, or opt out of the Program entirely at any time by notifying a Program representative by telephone at 1-800-633-1610 or by sending a letter to Sanofi US Customer Service P.O. Box 5925 Mailstop 55A-220A Bridgewater, NJ 08807. I also understand that the Services may be revised, changed, or terminated at any time.

Questions or comments? Contact Sanofi US, or call 1-844-643-7346 to contact Regeneron Pharmaceuticals, Inc.

By clicking 'Submit,' I confirm that all information provided in this form is true, complete and accurate.