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Assistance with paying for GOCOVRI®*
If you and your doctor determine that GOCOVRI® is right for you, the GOCOVRI Onboard® program can help.
A GOCOVRI® care coordinator can work with you to see if you’re eligible for assistance with paying for GOCOVRI®.
Here are the available programs:
If you have a commercial health plan and participate in the GOCOVRI® Co-pay Assistance Program, you'll pay $20 per prescription
If you don’t have insurance, your insurance doesn’t cover† GOCOVRI®, or if you can’t afford GOCOVRI®, the Patient Assistance Program can help you get GOCOVRI® at no cost
See Terms & Conditions for these programs.
*For details, see terms & conditions for the Co-pay Program, the Patient Assistance Program, and the Independent Charitable Foundations Program.
†Financial and medical eligibility requirements vary by organization.
‡After prior authorization and appeal processes have been exhausted.
*No purchase of GOCOVRI® or enrollment into GOCOVRI Onboard® is required. See terms & conditions here.
If your doctor determines GOCOVRI® is right for you, GOCOVRI Onboard® can help. To receive GOCOVRI®, our specialty pharmacy partner needs to speak to you
Once our specialty pharmacy confirms your address over the phone, they will arrange express delivery of GOCOVRI® directly to your door, with no need to go to the pharmacy
After you receive GOCOVRI®, your patient care coordinator will call you to answer any questions you may have and to discuss next steps
The Free Trial Program provides eligible patients with a 28-day supply of GOCOVRI®. There is no purchase obligation to participate in the Free Trial Program. This Program is only for patients who are new to treatment and have an on-label prescription. Patients who elect to discontinue GOCOVRI ®treatment after the Free Trial may be eligible to receive an additional 7-day supply of GOCOVRI® at a lower dose. Program offer expires December 31, 2021. Adamas reserves the right to modify or cancel this Program without notice at any time.
Patient: By signing on page 1, I certify that I will not seek reimbursement or credit for my Free Trial prescription from any insurer, health plan, or government program. If I am a member of a Medicare Part D plan, I will not seek to have this prescription or any cost associated with it counted as part of my out-of-pocket cost for prescription drugs. I certify that I have never used GOCOVRI® before, including receiving a physical sample from my doctor.
Prescriber: By signing on page 1, I certify that this prescription is on label and the patient has not yet started GOCOVRI® treatment. I agree that I will not seek reimbursement from any government program or third-party insurer for any medication dispensed to the patient through the Free Trial Program. I certify that I have never prescribed or given GOCOVRI® to this patient before, including the provision of a physical sample from my office.
Under the GOCOVRI® Co-pay Program, eligible patients pay no more than $20 in co-pay/cost-sharing for each GOCOVRI® prescription filled, up to the annual limit per 12-month period. If the patient dosage requires 2 separate prescriptions of GOCOVRI® per month, GOCOVRI® Co-pay Program assistance may be applied to both prescriptions.
In order to be eligible for the GOCOVRI® Co-pay Program, the patient must be a resident of the United States or Puerto Rico and have a valid prescription for GOCOVRI® for an indication included in the FDA-approved product labeling. The GOCOVRI® Co-pay Program is available ONLY for patients with commercial (private or non-governmental) insurance. This offer is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, TRICARE, the VA healthcare program, or any other federal or state healthcare program ("Government Programs"). Patients who obtain Government Programs coverage during their enrollment period will no longer be eligible for the program. The GOCOVRI® Co-pay Program is not valid for cash-paying patients or where the patients plan reimburses for the entire cost of his or her prescription.
This Co-pay Program is not health insurance. The GOCOVRI® Co-pay Program will cover the patients co-pay/cost-sharing costs for GOCOVRI® only. It does not cover any other healthcare provider charges or any other treatment costs. Eligible patients may be responsible for deductibles or other out-of-pocket costs, depending on their specific healthcare benefits.
Use of GOCOVRI® Co-pay Program does not obligate use or continuing use of any specific product or provider. Use of this Co-pay Program must be consistent with all relevant health insurance requirements and payer policies. Participating patients and pharmacies must report use of the GOCOVRI® Co-pay Program to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the Co-pay Program, as may be required by the patients insurance provider or health plan. Participating patients and pharmacies agree not to seek reimbursement for all or any part of the benefit received by the patient through the offer. Pharmacies may not advertise or otherwise use the Co-pay Program as a means of promoting their services or products to patients.
The patient or patients guardian must be 18 years of age or older to utilize the GOCOVRI® Co-pay Program. The GOCOVRI® Co-pay Program will be accepted by participating pharmacies only. This offer cannot be combined with any other rebate/coupon, free trial, or similar offer. This offer is void where prohibited by law, taxed, or restricted. This offer is non-transferrable. No substitutions are permitted.
This program expires within 12 months from enrollment. Adamas Pharmaceuticals, Inc. reserves the right to rescind, revoke, or amend the program without notice at any time.
For information about the eligibility requirements for the Adamas Patient Assistance Program, call 1-844-GOCOVRI (1-844-462-6874).