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GOCOVRI ONBOARDTM Terms and Conditions

Co-Pay Savings PROGRAM

Under the GOCOVRITM 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 (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 health care 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 the patient’s co-pay/cost-sharing costs for GOCOVRI only. It does not cover any other health care provider charges or any other treatment costs. Eligible patients may be responsible for deductibles or other out-of-pocket costs, depending upon their specific health care 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 the 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.

QUICKSTART PROGRAM

The QuickStart Program provides eligible patients with up to a 28-day supply of GOCOVRI. There is no purchase obligation to participate in the QuickStart Program. A minimum of a 5 business-day insurance verification period is required. This Program is only available to patients who are new to treatment and have an on-label prescription for GOCOVRI.

You may not seek reimbursement or credit from any insurer, health plan, or government program for free product received under the QuickStart Program. For any patient that is a member of a Medicare Part D plan, the QuickStart prescription, or any cost associated with it may not be counted as part of the out-of-pocket cost for prescription drugs.

Adamas Pharmaceuticals, Inc. reserves the right to rescind, revoke, or amend the QuickStart Program without notice at any time.

For additional information, call 1-844-GOCOVRI (1-844-462-6874).

PATIENT ASSISTANCE PROGRAM

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

REGISTER FOR GOCOVRI UPDATES

Sign up to stay informed, or call 1-844-GOCOVRI and learn more about GOCOVRI in your area.

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Important Safety Information

Indication

GOCOVRI™ (amantadine) extended release capsules is indicated for the treatment of dyskinesia in patients with Parkinson’s disease receiving levodopa-based therapy, with or without concomitant dopaminergic medications.

Contraindications

GOCOVRI™ (amantadine) is contraindicated in patients with creatinine clearance below 15 mL/min/1.73 m2.

Warnings and Precautions

Falling Asleep During Activities of Daily Living and Somnolence: Patients treated with Parkinson’s disease medications have reported falling asleep during activities of daily living. If a patient develops daytime sleepiness during activities that require full attention (e.g., driving a motor vehicle, conversations, eating), GOCOVRI should ordinarily be discontinued or the patient should be advised to avoid potentially dangerous activities.

Suicidality and Depression: Monitor patients for depression, including suicidal ideation or behavior. Prescribers should consider whether the benefits outweigh the risks of treatment with GOCOVRI in patients with a history of suicidality or depression.

Hallucinations/Psychotic Behavior: Patients with a major psychotic disorder should ordinarily not be treated with GOCOVRI because of the risk of exacerbating psychosis. Observe patients for the occurrence of hallucinations throughout treatment, especially at initiation and after dose increases.

Dizziness and Orthostatic Hypotension: Monitor patients for dizziness and orthostatic hypotension, especially after starting GOCOVRI or increasing the dose.

Withdrawal-Emergent Hyperpyrexia and Confusion: Rapid dose reduction or abrupt discontinuation of GOCOVRI, may cause an increase in the symptoms of Parkinson’s disease or cause delirium, agitation, delusions, hallucinations, paranoid reaction, stupor, anxiety, depression, or slurred speech. Avoid sudden discontinuation of GOCOVRI.

Impulse Control/Compulsive Behaviors: Patients may experience urges (e.g. gambling, sexual, money spending, binge eating) and the inability to control them. It is important for prescribers to ask patients or their caregivers about the development of new or increased urges. Consider dose reduction or stopping medications.

Adverse Reactions

The most common adverse reactions (>10%) were hallucination, dizziness, dry mouth, peripheral edema, constipation, fall, and orthostatic hypotension.

Drug Interactions

Other Anticholinergic Drugs: The dose of GOCOVRI should be reduced if atropine-like effects are observed.

Drugs Affecting Urinary pH: The pH of the urine has been reported to influence the excretion rate of amantadine. Monitor for efficacy or adverse reactions under conditions that alter the urine pH.

Alcohol: Concomitant use with alcohol is not recommended, as it may increase the potential for CNS effects such as dizziness, confusion, lightheadedness, and orthostatic hypotension.

Indication

GOCOVRI™ (amantadine) extended release capsules is indicated for the treatment of dyskinesia in patients with Parkinson’s disease receiving levodopa-based therapy, with or without concomitant dopaminergic medications.