From California? Download this form instead.
Just fill out this form and bring it to your doctor. We'll take it from there
If you've made up your mind to ask your doctor about GILENYA®, here's a great way to check another to-do item off your list: bring the form to start GILENYA with you on your visit. (If you're a California resident, you should download this form instead.)
Simply fill out your contact info and insurance details at the top, and hand it off to your doctor to complete the rest. Your doctor will send it in for you, so don't worry about that part. Once the GILENYA Care Team receives this form, they'll be able to start scheduling tests, answering questions, and determining whether you qualify for a $0 co-pay* (most people do).
Bringing this form with you isn't strictly necessary, but taking it with you will help speed up the process.
It's important for you and your doctor to understand each other.
- –JuJuan M.
- GILENYA Guide
*In 2013, 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.