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 health care professional. We'll take it from there

If you've made up your mind to ask your health care professional about GILENYA®, here's a great way to check another to-do item off your list: bring the GILENYA Start Form with you on your visit.

If you are the caregiver of a child between the ages of 10 and 17 who is starting GILENYA, please use the GILENYA Start Form for children and bring it to your child's next doctor visit.

Simply fill out your portion of the form, and your health care professional 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

Please be sure to fill out all required sections of the GILENYA Start Form and sign. Incomplete areas may delay the start of treatment.

Bringing this form with you isn't strictly necessary, but having 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-GILENYA (1-800-445-3692) 8:00 AM-9:00 PM ET, Mon-Fri (excludes public holidays). If you are the caregiver of a child between the ages of 10 and 17, reach out to our dedicated parent line 1-800-598-1410 during those same business hours.

For a more in-depth picture of what you can expect when starting GILENYA, click here.

*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 or are a child who is moving to 0.5 mg from the 0.25 mg dose.

In 2016, 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. Limitations apply. Valid only for those with commercial insurance. Offer not valid under Medicare, Medicaid or any other federal or state program. Not valid for cash-paying patients, where product is not covered by patient's commercial insurance, or where plan reimburses you for entire cost of your prescription drug. Offer is not valid where prohibited by law. Valid only in the US and Puerto Rico. This program is not health insurance. Offer may not be combined with any other rebate, coupon, or offer. This program is subject to termination or modification at any time.


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

Find out what sets it apart.


$0 CO-PAY?

The GILENYA Support Team can help set you up.

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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 or call

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



Discover why GILENYA may be right for you and find out how to get started. GILENYA delivers the info straight to you.