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.
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).