Ampyra Co-Pay Program

Funded

About

The Ampyra Co-Pay Program offers significant savings for patients using Ampyra. With the Ampyra Co-Pay Program, eligible patients may pay as little as $0 for their monthly prescription, benefiting from a maximum monthly benefit of $1,000. Enrollment is straightforward with a referral from your physician. This program is designed to make Ampyra more accessible by reducing out-of-pocket costs up to $12,000 annually.

Insurance requirements: Commercially insured

Enrollment Forms

Enrollment Form

Benefits

•$12000 annual maximum benefit

•12 maximum fills per year

Program Requirements

•Valid only for residents in the US and Puerto Rico

•Enrollment Required: Yes

•Coverage Required: No

•Needs Based: No

•Activation Required: No

Program Details

•Patients may pay as little as $0 for a monthly prescription

•Monthly maximum benefit is $1,000 for a onemonth supply (maximum benefit is $12,000 per year)

•Enrollment process begins with a referral from the physician to the program

•Complete all fields on prescription & service request form to avoid any delays in processing; fax form to 8888833053

•For any questions call AMPYRA Patient Support Services at 18888811918, Monday though Friday 8am8pm ET

Enrollment Forms

Enrollment Form