GO with support and easy access
Request samples today
Once you have identified an appropriate patient, samples of GOCOVRI® are available. Contact your local GOCOVRI representative to learn more. You may also request a representative now.
Downloadable Resources
How to Prescribe GOCOVRI
Learn how to e-prescribe, fax, or phone in a GOCOVRI prescription.
Prescription Form
Ready to get your patient started on GOCOVRI? Fill out this prescription form before they leave the office, then fax it to GOCOVRI Onboard® at 1-844-826-7626.
Letter of Medical Necessity
Use this sample letter to help you formally document medical necessity for GOCOVRI on behalf of your patients.
Letter of Appeal
In the event that insurance denies coverage, use this sample letter to help you write an appeal for medical necessity.
Patient Brochure
Help your patients better understand their condition and find more information about GOCOVRI using our patient brochure. For physical copies, contact your representative or request a representative now.
CMS-Coverage Determination Form
Found on the Centers for Medicare & Medicaid Services website, this form allows you, your patient, or their representative to request a coverage determination, including an exception, from a plan sponsor.
CMS Re-Determination Form
Found on the Centers for Medicare & Medicaid Services website, this form allows you, your patient, or their representative to appeal a denial of coverage from a plan sponsor.
GOCOVRI Efficacy, PK, & Dosing Brochure
Take a closer look at the studies and pharmacokinetics data behind GOCOVRI, as well as dosing and administration instructions.
GOCOVRI Onboard®: Dedicated to helping your patients access GOCOVRI®
$20 CO-PAY
Commercially insured patients who participate in the GOCOVRI Co-pay Assistance Program pay $20 per prescription* until the maximum annual benefit is reached.
This program provides new, eligible patients with a 4-week supply of GOCOVRI. No purchase is required for your patients to participate.†
Your GOCOVRI® Care Coordinator is a dedicated, single point-of-contact for you and your patients who partners with a specialty pharmacy to provide timely fulfillment.
In addition, GOCOVRI Onboard® offers:
- Benefits verification
- Electronic submission of prior authorizations through CoverMyMeds®
- Next-day delivery to patients each month
- Monthly follow-up from a specialty pharmacy to schedule deliveries to patients
- Answers to questions you or your patients may have
(1-844-462-6874)
8 am - 8 pm ET M-F
*This offer is valid for patients who have commercial (non-governmental-funded) insurance and must meet eligibility requirements. See full Terms & Conditions.
†No enrollment into GOCOVRI Onboard is required. See Terms & Conditions.
5 easy steps to get patients started with GOCOVRI Onboard®
Fill out, collect signatures, and fax the prescription form to GOCOVRI Onboard® at 1-844-826-7626. Be sure to complete the Prescription Form before your patient leaves the office.
A benefits verification is initiated.
If a prior authorization (PA) is required, GOCOVRI Onboard® will initiate the PA and send to your office via CoverMyMeds®. GOCOVRI Onboard® may reach out to you to ensure timely completion.
The specialty pharmacy will call your patient to schedule next-day delivery of GOCOVRI®.
Note: your patients will need to speak with the specialty pharmacy over the phone in order to schedule their first delivery. If the specialty pharmacy is not able to reach the patient, they may reach out to you to help facilitate contact.
The specialty pharmacy will follow up monthly to schedule recurring deliveries.
Curious what your peers think about GOCOVRI?
Head on over to our Peer Perspectives page and listen to neurologists and movement disorder specialists discuss how they’ve incorporated GOCOVRI into their practice.
Get clinical information on GOCOVRI
Get the latest news and updates about GOCOVRI®, learn about upcoming events, and more.
TERMS & CONDITIONS
GOCOVRI Free Trial Program
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, 2024. Adamas reserves the right to modify or cancel this Program without notice at any time.
Patient: By signing on page 1, I certify that I will not seek reimbursement or credit for my Free Trial prescription from any insurer, health plan, or government program. If I am a member of a Medicare Part D plan, I 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. I certify that I have never used GOCOVRI before, including receiving a physical sample from my doctor.
Prescriber: By signing on page 1, I certify that this prescription is on label and the patient has not yet started GOCOVRI treatment. I agree that I will not seek reimbursement from any government program or third-party insurer for any medication dispensed to the patient through the Free Trial Program. I certify that I have never prescribed or given GOCOVRI to this patient before, including the provision of a physical sample from my office.
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 until the maximum annual benefit is reached. 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 GOCOVR 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).