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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 my 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, 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 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 for the Adamas Patient Assistance Program, call 1-844-GOCOVRI (1-844-462-6874).