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:

English

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 Uninsured or Underinsured
Those with Part D Eligible? No
Income At or below 500% of FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
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 September 27, 2018