Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 3.
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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: 844-8267626
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Gocovri Onboard Treatment Form

Gocovri Important Facts

 

Medications

  • amantadine capsule; extended release (Gocovri) 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
   

Application

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
   

Medication

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 November 16, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
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Rx Outreach Medications

This program provides medication at low cost. (Most brand names are provided for reference purposes only)

Provided by: Rx Outreach

PO Box 66536
St. Louis, MO 63166-6536

TEL: 888-796-1234


FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Rx Outreach Application

Rx Outreach Diabetic Supplies Order Form (Prodigy)

Rx Outreach Refills and New Prescription Form

Rx Outreach Medication List

 

Medications

  • amantadine () 
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income At or below 300% of FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must reside in the US
   

Application

Obtaining Call, download or apply online
Receiving Faxed, mailed or downloaded from website
Returning Fax or E-Prescribe online
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Medications sent if accepted. If denied patient and doctor notified
Decision Timeframe Usually same day
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Not specified
Refill Process Company contacts patient to arrange
Limit Only limited by manufacturer's guidelines
Re-application New application yearly
   

Additional Information

Some medications are available for a fee of $20 for up to a 180 day supply.
Check the Rx Outreach website for the exact price and most current medication list.

Contact Program for Spanish Application(s)/Form(s).


Updated October 03, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 3.
 

HealthWell Foundation Copay Program

This is a copay assistance program

Provided by: HealthWell Foundation

PO Box 220410
Chantilly, VA 20153-0410

TEL: 800-675-8416


FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

HealthWell Foundation Copay Program: Contact program

 

Medications

  • amantadine () 
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside in the US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months
   

Additional Information

This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease.

Call for most recent medications as the list is subject to change.
Updated May 22, 2017