GOCOVRI Onboard & Free Trial Option Terms & Conditions

FREE TRIAL OPTION

The Free Trial Program provides eligible patients with a 28-day supply of GOCOVRI. There is no purhcase 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 addional 7-day supply of GOCOVRI at a lower dose. Program offer expires December 31, 2019. Adamas reserves the right to modify or cancel this Program without notice at any time.

Patients must certify that they will not seek reimbursement or credit for the Free Trial prescription from any insurer, health plan, or government program. If the patient is a member of a Medicare Part D plan, they will not seek to have this prescription, or any cost associated with it counted as part of an out-of-pocket cost for prescription drugs.

Prescribers must certify that the prescription is on label and the patient has not yet started GOCOVRI treatment and must not seek reimbursement from any government program or third-party insurer for any medication dispensed to the patient through the Free Trial Program.

CO-PAY ASSISTANCE PROGRAM

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 twelve (12) month period. If the patient dosage requires two 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 patient’s 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 patient’s 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 patient’s 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.

Patient or patient’s 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

PATIENT ASSISTANCE PROGRAM

For information about the eligibility requirements for the Adamas Patient Assistance Program, call 1-844-GOCOVRI (1-844-462-6874).

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IMPORTANT SAFETY INFORMATION

Before taking GOCOVRI, tell your doctor about all medical conditions, including if you:

  • have kidney problems; unexpected sleepiness; take medicine to help you sleep or that makes you drowsy; have mental problems, such as suicidal thoughts, depression, or hallucinations; unusual urges including gambling, increased sex drive, compulsive eating, or shopping; or if you drink alcoholic beverages

  • are pregnant or plan to become pregnant or are breastfeeding or plan to breastfeed. GOCOVRI may harm your unborn baby and can pass into your breastmilk

Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Especially tell your doctor if you take medicines like sodium bicarbonate.

What should I avoid while taking GOCOVRI?

  • Do not take GOCOVRI if you have severe kidney problems

  • Do not drive, operate machinery, or do other dangerous activities until you know how GOCOVRI affects you

  • Do not drink alcohol while taking GOCOVRI as it can increase your chances of serious side effects

  • Do not stop or change the dose of GOCOVRI before talking with your doctor. Call your healthcare provider if you have symptoms of withdrawal such as fever, confusion, or severe muscle stiffness

  • Do not take a flu nasal spray while taking GOCOVRI, but you can receive a flu shot

What are the possible side effects of GOCOVRI?

GOCOVRI may cause serious side effects, including:

  • falling asleep during normal activities, such as driving, talking, or eating, while taking GOCOVRI. You may fall asleep without being drowsy or warning. The risk is greater if you take GOCOVRI with medicines that cause drowsiness

  • suicidal thoughts or actions and depression

  • occurrence or worsening of hallucinations (seeing or hearing things that are not real)

  • feeling dizzy, faint or light headed, especially when you stand up too quickly, when first starting GOCOVRI, or if your dose has been increased

  • unusual urges including gambling, sexual, spending money, binge eating, and the inability to control them
    If you or your family notices that you are developing any new, unusual or sudden changes in behavior or related symptoms, tell your healthcare provider right away.

Be sure to take your medicine at bedtime as instructed. You may take GOCOVRI with or without food.

View the GOCOVRI Important Facts for additional Important Safety Information

WHAT IS GOCOVRI?

Tap to see Important Safety Information

GOCOVRI® (amantadine) extended release capsules is a prescription medicine for treating dyskinesia (sudden uncontrolled movements) in Parkinson’s disease patients treated with levodopa therapy, with or without other medicines that increase the effects of dopamine in the brain. It is not known if GOCOVRI is safe and effective in children.

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