Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  

Gocovri Onboard

This program provides brand name medications at no or low cost

Provided by: Adamas Pharmaceuticals, Inc

130 Enterprise Drive,
Pittsburgh, PA 15275

TEL: 844-462-6874

FAX: 844-826-7626
Languages Spoken:


Program Website


Patient Assistance Applications

Gocovri Onboard Treatment Form

Gocovri Important Facts


Brand Name Medications Covered

  • Gocovri capsule; extended release

Generic Name

  • amantadine capsule; extended release

Eligibility Requirements   

Insurance Status Must be uninsured
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Must be 18 yr old or older
US Residency Required? Must be citizen


Obtaining Call, download or apply online
Receiving Faxed or downloaded from website
Returning Fax
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient and Doctor are notified
Decision Timeframe 2-3 business days


Amount/Supply As prescribed by Doctor
Sent To Patient's home, unless otherwise noted
Delivery Time Once approved; within 2 business days
Refill Process Company contacts patient to arrange
Limit Contact the program for details
Re-application Determined case by case

Additional Information

This program also provides copay assistance.

Updated June 27, 2018