It's important for you and your doctor to understand each other.
- –JuJuan M.
- GILENYA Guide
Just fill out this form and bring it to your doctor. We'll take it from there
Simply fill out your portion of the form, and your doctor will handle the rest. From there, you'll connect with a member of the GILENYA Support Team to schedule tests, answer questions, and determine whether you qualify for a $0 co-pay* (most people do).
- Start by reading the Patient Authorization and Marketing Consent Pages. Once you've done that, fill out all of Section 1 of the Service Request Form, and don't forget to sign the form.
- Make sure you give us your phone number. Why? Because the GILENYA® Support Team will be calling you soon to discuss your insurance coverage and co-pay support eligibility. As part of the GILENYA Go Program™, your GILENYA Support Team is here to help you every step of the way as you begin treatment. By checking the "OK to leave a message" box, we can leave a message if you cannot answer the phone.
- Your doctor will take care of Section 2 and will fax the form to us.
Please be sure to fill out all required sections of the Service Request Form and sign. Incomplete areas may delay the start of treatment.
Bringing this form with you isn't strictly necessary, but taking it with you will help speed up the process.
- The GILENYA Support Team will give you a call to answer any questions you might have. A Support Team member will also call you to confirm your insurance coverage and discuss next steps based on your doctor's selections.
- You'll also receive a Welcome Kit from GILENYA in the next few days, so keep an eye on your mailbox!
- Your doctor may have given you a brochure that includes contact information for your GILENYA Support Team. Make sure you don't leave without your GILENYA Support Team's business cards. After all, it's nice to know who you're talking to!
Please note—this call might come from an unfamiliar phone number or 1-800-445-3692, the number for the GILENYA Support Team.
If you have any questions, feel free to call the GILENYA Support Team at 1-800-445-3692.
For a more in depth picture of what you can expect when starting GILENYA, click here.
*In 2014, most eligible patients paid a $0 co-pay. Call 1-800-GILENYA for details. People for whom GILENYA has been prescribed are required to report any benefits they receive through the GILENYA Prescription Co-Pay Support Program to their commercial insurance company. This offer is not valid for prescriptions for which payment may be made in whole or in part under federal or state health programs, including but not limited to Medicare or Medicaid. This program is subject to termination or modification at any time.
†GILENYA can result in a slow heart rate when first taken. You will be observed by a health care professional for at least 6 hours after you take your first dose. You may need to repeat this monitoring if you miss a dose.