GOCOVRI Onboard^® & FREE TRIAL OPTION TERMS & CONDITIONS

Free trial option

The Free Trial Program provides eligible patients with a 28-day supply of GOCOVRI^®. There is no purchase obligation to participate in the Free Trial Program. This Program is only for patients who are new to treatment and have an on-label prescription. Patients who elect to discontinue GOCOVRI^® treatment after the Free Trial may be eligible to receive an additional 7-day supply of GOCOVRI^® at a lower dose. Program offer expires December 31, 2021. Adamas reserves the right to modify or cancel this Program without notice at any time.

Patients must certify that they will not seek reimbursement or credit for the Free Trial prescription from any insurer, health plan, or government program. If the patient is a member of a Medicare Part D plan, they will not seek to have this prescription, or any cost associated with it counted as part of an out-of-pocket cost for prescription drugs.

Prescribers must certify that the prescription is on label and the patient has not yet started GOCOVRI^® treatment and must not seek reimbursement from any government program or third-party insurer for any medication dispensed to the patient through the Free Trial Program.

Co-pay assistance program

Under the GOCOVRI^® 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 of $10,000 per calendar year. 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, Puerto Rico Government Health Insurance Plan, 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 on their specific health care benefits. Patients are responsible for reporting the receipt of all Co-Pay Program benefits or reimbursement received 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, if required.

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.

Patient assistance program

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