Gocovri Patient Assistance Programs

Gocovri: Apply for prescription assistance below

If you are eligible, the programs below can help you afford Gocovri. Review the information to see if you qualify. The applications are available in Adobe PDF format and should be mailed directly to the provider of the patient assistance program.

If you have any questions, please call the telephone number for the program (not PharmacyChecker.com) or go to the program website.

Looking for a different medication?

Patient Access Network Foundation (PAN)

(Program 1 of 2 — Scroll down to see them all)

Provided by: Patient Access Network Foundation
None
TEL: 866-316-7263
FAX: 866-316-7261
Languages Spoken:
English, Spanish, Others By Translation Service
Program Website
Medications
  • Gocovri capsule; extended release (amantadine capsule; extended release)
Eligibility Requirements
  • Insurance Status *See Additional Information section below
  • Those with Part D Elibible? Determined case by case
  • Income Between 400-500% of FPL
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. Residency Required? Must reside and receive treatment in US
Application
  • Obtaining Call or complete online
  • Receiving Complete online or by phone
  • Returning Complete online or by phone
  • Doctor's Action Will be discussed with patient and Doctor after request is received
  • Applicant's Action Call for information or inform doctor that he/she is in need
  • Decision Communicated Patient and Doctor notified in writing
  • Decision Timeframe Within 48 hours
Medication
  • Amount/Supply Not applicable
  • Sent To Patient sent card to be used at pharmacy
  • Delivery Time Once approved; shipped same day
  • Refill Proces Patient presents voucher/card to pharmacy for each refill
  • Limit None
  • Re-application New application every 12 months
Additional Information
*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details.
Updated July 10, 2018

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for Gocovri prices here.

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Gocovri Onboard

(Program 2 of 2 — Scroll down to see them all)

Provided by: Adamas Pharmaceuticals, Inc
130 Enterprise Drive, Pittsburgh, PA 15275
TEL: 844-462-6874
FAX: 844-826-7626
Languages Spoken:
English
Program Website
Medications
  • Gocovri capsule; extended release (amantadine capsule; extended release)
Eligibility Requirements
  • Insurance Status Must be uninsured
  • Those with Part D Elibible? No
  • Income Not disclosed
  • Diagnosis/Medical Criteria Must be 18 yr old or older
  • U.S. Residency Required? The patient must also be a US citizen.
Application
  • Obtaining Call, download or apply online
  • Receiving Faxed or downloaded from website
  • Returning The completed application must be faxed back.
  • 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 Proces 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

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for Gocovri prices here.

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