Welcome to the GILENYA® Co-Pay Support Program. Please provide the below information to determine co-pay savings eligibility.

Patient First Name* Patient Last Name*
Patient Street Address - Line 1* Patient Street Address - Line 2
Patient City* Patient State* Patient Zip*
Patient Date of Birth (MM/DD/YYYY)* Patient Gender*
Patient Phone Number (XXX-XXX-XXXX)* Patient Email
What type of prescription coverage does the patient have?*

In order to be eligible for co-pay savings, please read and agree to the following statements:

*Fields are required.