Download the Form to Start GILENYA

MS treatment form
  • 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

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.

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).

Here's how to get the ball rolling

Bringing this form with you isn't strictly necessary, but taking it with you will help speed up the process.

What Happens Next?

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.

WHY CHOOSE GILENYA?

GILENYA is the most prescribed once-a-day pill* for relapsing MS.

Find out what sets it apart.

GO

$0 CO-PAY?

The GILENYA Support Team can help set you up.

GO

Kayte S. on knowing your options

Novartis ISI Novartis ISI gpr@outcome.com www.gilenyapregnancyregistry.com www.fda.gov/Safety/MedWatch Full Prescribing Information Patient Medication Guide
Novartis ISI gpr@outcome.com www.gilenyapregnancyregistry.com www.fda.gov/Safety/MedWatch Full Prescribing Information Patient Medication Guide
Novartis ISI gpr@outcome.com www.gilenyapregnancyregistry.com www.fda.gov/Safety/MedWatch Full Prescribing Information Patient Medication Guide
 
Novartis

Speak up and share your message. Tell multiple sclerosis (MS) how you really feel by posting your message on our "HEY MS" message board.

Make sure your voice is heard. We love that you want to say "Take This!" to relapsing MS, but there are still some words even we can't use—words that might not be appropriate. They're defined in the Community Guidelines below. But have no fear; we'll give you a heads up if you use any problematic words by highlighting them after you hit submit. So, go for it, and tell relapsing MS how you really feel!

  • Do not include medical advice or any non-approved use of GILENYA

  • No profane, indecent, or inappropriate language in your message or image, please (a no-no)

  • Avoid using your full name and/or e-mail address in your message, so this personal information remains private and protected

  • Do not include spam, such as links to or URLs for other websites or social networks in your message

  • Refrain from sharing any treatment and/or dosage information, as well as names of specific medicines (brand name or generic) and product manufacturers

  • Avoid mention of side effects from GILENYA. We take drug product safety seriously. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call
    1-800-FDA-1088

Please note that in order to comply with our Community Guidelines as well as the FDA's Prescription Drug Advertising Guidelines, your statement may be subject to modification, while maintaining the spirit of your message. Your photo and statement may be used in other GILENYA marketing materials

9/15 T-GYA-1316873