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 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).
- Start by reading the Patient Authorization and Marketing Consent Pages. Once you've done that, fill out all of Section 1 of the GILENYA Start 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 health care professional will take care of Section 2 and will fax the form to us.
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.
- 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 health care professional's selections.
- You'll also receive a Welcome Kit from GILENYA in the next few days, so keep an eye on your mailbox!
- Your health care professional 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 are the caregiver of a child between the ages of 10 and 17, you will receive a call from our dedicated parent line 1-800-598-1410.
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.
†Limitations apply. Valid only for those with private insurance. The Program includes the Co-pay Card, Payment Card (if applicable), and Rebate, with a combined annual limit up to $18,000. Patient is responsible for any costs once limit is reached in a calendar year. Program not valid (i) under Medicare, Medicaid, TRICARE, VA, DoD, or any other federal or state health care program, (ii) where patient is not using insurance coverage at all, (iii) where the patient's insurance plan reimburses for the entire cost of the drug, or (iv) where product is not covered by patient's insurance. The value of this program is exclusively for the benefit of patients and is intended to be credited towards patient out-of-pocket obligations and maximums, including applicable co-payments, coinsurance, and deductibles. Program is not valid where prohibited by law. Patient may not seek reimbursement for the value received from this program from other parties, including any health insurance program or plan, flexible spending account, or health care savings account. Patient is responsible for complying with any applicable limitations and requirements of their health plan related to the use of the Program. Valid only in the United States and Puerto Rico. This Program is not health insurance. Program may not be combined with any third-party rebate, coupon, or offer. Proof of purchase may be required. Novartis reserves the right to rescind, revoke, or amend the Program and discontinue support at any time without notice.