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Prescribing OSMOLEX® ER (amantadine) for Your Patients

OSMOLEX ER is not available in retail pharmacies. Each patient must be enrolled through AccessOsmolex™, a program designed to provide access and financial support to patients.

Instructions for Healthcare Providers

Once you have identified an OSMOLEX ER patient, follow these steps to process a prescription through the AccessOsmolex Support Center.

STEPS

  • 1 Ensure patient consent is given to enroll in the AccessOsmolex program. You have the option of having the patient sign the patient consent form to send along with the enrollment and prescription form, or AccessOsmolex will call the patient to gain verbal consent.
  • 2 Fill out enrollment and prescription form completely and include a copy of the patient’s insurance card (front and back).
  • 3 Include Medical Information on the form or accompanying the form.
  • 4 Ensure the Prescription Information portion is completed for Initial and/or Maintenance Dose. If one dose will not be utilized, check the box indicating that the dose will not be utilized.
  • 5 Ensure the Prescriber Named in Section 3 has signed the Enrollment and Prescription form. Stamps are not permitted.
  • 6 Fax all necessary documents to AccessOsmolex at 1-866-750-9516.
Patient enrollment and prescription form

Do you typically prescribe electronically?

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E-scribe in your patient’s electronic medical record (EMR) and choose to print the Rx form instead of electronically submit. EMR will have a record of the prescription.
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Scan in the AccessOsmolex Enrollment and Prescription form and it will be a part of the medical record.
Patient enrollment and prescription downloadable form

Download the patient enrollment and prescription form

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Patient consent downloadable form

Download the patient
consent form

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Patient refill rates of OSMOLEX ER January through October 20191:

Seven out of 10 people icon 70% Created with Sketch.

of patients who started treatment with OSMOLEX ER therapy have refilled their prescription for 90 days or more*

Six out of 10 people icon 60% Created with Sketch.

of patients who started treatment with OSMOLEX ER therapy have refilled their prescription for 180 days or more†

These data represent estimates of duration of therapy calculated as last shipment date minus first shipment date plus days supplied of last shipment and assumes the patient took medication throughout the estimated duration of therapy. These data may not correlate to clinical outcomes.

*90-Day Exclusion Criteria:

  • 90 days from first shipment falls outside 10/16/2019 (last date in sample) OR
  • Duration of Therapy is <90, but 30 days have not lapsed between last shipment and 10/16/2019
  • After these filters were applied, 289 patients were eligible for 90-day persistence Y/N – 201/289 (70%) met criteria for “Y”

†180-Day Exclusion Criteria:

  • 180 days from first shipment falls outside 10/16/2019 (last date in sample) OR
  • Duration of Therapy is <180, but 30 days have not lapsed between last shipment and 10/16/2019
  • After these filters were applied, 112 patients were eligible for 180-day persistence Y/N – 66/112 (59%) met criteria for “Y”
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References:

  1. Data source: UCB, January-October 16th 2019. Data set size: 474 patients.
  2. Medicare Part D: A First Look at Prescription Drug Plans in 2018. Henry J. Kaiser Family Foundation website. https://www.kff.org/report-section/medicare-part-d-a-first-look-at-prescription-drug-plans-in-2018-findings/. Published October 13, 2017. Accessed April 12, 2018.
  3. 2017 Employer Health Benefits Survey. Henry J. Kaiser Family Foundation website. https://www.kff.org/report-section/ehbs-2017-section-9-prescription-drug-benefits/. Published September 19, 2017. Accessed April 12, 2018.