Access Support & Tools

Alpha Cognition is committed to helping support your appropriate residents start and continue taking ZUNVEYL.

Submit a Service Request Form or download useful tools to help you and your staff with access and coverage for residents who have been prescribed ZUNVEYL.

To request prior authorization or appeal assistance for ZUNVEYL, complete the Service Request Form below.

Start Service Request Form

Note: Completion of a Service Request form does not initiate treatment but is intended to request access and reimbursement services.

Prefer to print and fax in the service request form? Download a PDF version of the form here.

    Prior Authorization or Appeal Service Request Form

    Important Notes:

    • This form should be completed by a prescribing physician, nurse, or facility pharmacist to request prior authorization or appeals support. It does not initiate treatment.

    • If requesting services for multiple residents on a single form, they must all be under the same Facility and Prescriber. A new form must be submitted for a different facility and/or prescriber.


    Please note: You may list up to 10 residents on this form from the same facility and prescriber above.

    Resident



    Prescriber Authorization

    I attest that I have obtained written permission, in the event it is required under applicable federal and/or state law, of my patients (or the patients’ legal representative) for the release of my patients’ Protected Health Information (“PHI”) to Alpha Cognition Inc. or its representatives or agents (collectively “Alpha Cognition”) as may be necessary for the patients’ participation in a program designed to assist patients in determining their insurance coverage for ZUNVEYL that I have elected to prescribe. I direct Alpha Cognition to convey, on my behalf, any prescription information delivered to Alpha Cognition for ZUNVEYL by any means under applicable law to the dispensing pharmacy chosen by or for the patients, to the patients’ health insurance company, or to other third parties as may be necessary to assist these patients with filling their prescription for ZUNVEYL, with securing any insurance coverage for ZUNVEYL to which the patients are entitled, or other third parties to assist with patient assistance or reduced-cost medication. I understand I am to comply with the state-specific prescription requirements such as e-prescribing, state-specific prescription form, fax language, etc. I agree that Alpha Cognition may contact me for additional information relating to ZUNVEYL, including but not limited to via email, fax, and telephone. I authorize Alpha Cognition to transmit the above prescription to the pharmacy. Please provide an email to receive a confirmation of this submission.

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    Access & Reimbursement Tools

    Download the tools below to help navigate access and reimbursement for ZUNVEYL.

    Guide to ZUNVEYL PAs & Step-Edits

    A checklist of requirements for ZUNVEYL prior authorizations and possible step-edits.

    Download

    Letter of Medical Necessity Templates

    Templates to write a letter to establish medical necessity, which payers may require for a patient prescribed ZUNVEYL.

    Download

    Medicare Smoothing & Extra Help Program

    A resource providing an overview of Medicare drug costs and payment plans.

    Download

    Need Additional Assistance with ZUNVEYL Prior Authorizations?

    CoverMyMeds is an online tool that lets prescribers send and track prior authorizations with insurance plans. Visit CoverMyMeds.health or call 1-866-452-5017.

    To contact an Access and Reimbursement Specialist, click here.

    INDICATION AND USAGE

    ZUNVEYL is a cholinesterase inhibitor indicated for the treatment of mild to moderate dementia of the Alzheimer's type in adults.

    IMPORTANT SAFETY INFORMATION

    CONTRAINDICATIONS

    ZUNVEYL is contraindicated in patients with known hypersensitivity to benzgalantamine, galantamine, or to any inactive ingredients in ZUNVEYL. Serious skin reactions have occurred.

    WARNINGS AND PRECAUTIONS

    Serious Skin Reactions: Serious skin reactions (Stevens-Johnson syndrome and acute generalized exanthematous pustulosis) have been reported in patients receiving galantamine (the active metabolite of ZUNVEYL tablets). If signs or symptoms suggest a serious skin reaction, use of this drug should not be resumed, and alternative therapy should be considered.

    Anesthesia: See Drug Interactions Section

    Cardiovascular Conditions: Cholinesterase inhibitors, including ZUNVEYL, have vagotonic effects on the sinoatrial and atrioventricular nodes, leading to bradycardia and AV block. Bradycardia and all types of heart block have been reported in patients taking cholinesterase inhibitors, both with and without known underlying cardiac conduction abnormalities. Therefore, all patients should be considered at risk for adverse effects on cardiac conduction.

    Patients treated with galantamine up to 24 mg/day using the recommended dosing schedule showed a dose-related increase in risk of syncope.

    Gastrointestinal Conditions: Cholinesterase inhibitors, including ZUNVEYL, may increase gastric acid secretion. Patients should be monitored closely for active or occult gastrointestinal bleeding, especially those with a history of ulcer disease or those receiving concurrent nonsteroidal anti-inflammatory drugs (NSAIDs). Clinical studies of galantamine have shown no increase, relative to placebo, in the incidence of either peptic ulcer disease or gastrointestinal bleeding.

    Galantamine has been shown to produce nausea, vomiting, diarrhea, anorexia, and weight loss. Monitor the patient's weight during therapy with ZUNVEYL.

    Genitourinary Conditions: Although this was not observed in clinical trials with galantamine, cholinesterase inhibitors, including ZUNVEYL, may cause bladder outflow obstruction.

    Neurological Conditions: Cholinesterase inhibitors are believed to have some potential to cause generalized convulsions. Seizure activity may also be a manifestation of Alzheimer's disease. Patients with Alzheimer's disease should be monitored closely for seizures while taking ZUNVEYL.

    Pulmonary Conditions: Cholinesterase inhibitors, including ZUNVEYL, should be prescribed with care to patients with a history of severe asthma or obstructive pulmonary disease. Monitor for respiratory adverse reactions.

    ADVERSE REACTIONS

    The most common adverse reactions with galantamine tablets (≥5%) were nausea, vomiting, diarrhea, dizziness, headache, and decreased appetite.

    DRUG INTERACTIONS

    Use with Anticholinergics: Galantamine has the potential to interfere with the activity of anticholinergic medications.

    Use with Cholinomimetics and Other Cholinesterase Inhibitors: A synergistic effect is expected when cholinesterase inhibitors are given concurrently with succinylcholine, other cholinesterase inhibitors, similar neuromuscular blocking agents or cholinergic agonists such as bethanechol.

    USE IN SPECIFIC POPULATIONS

    Pregnancy: Based on animal data may cause fetal harm.

    Hepatic Impairment: In patients with moderate hepatic impairment, a decrease in clearance of galantamine was observed; therefore, a dosage adjustment is recommended. Use of ZUNVEYL in patients with severe hepatic impairment is not recommended.

    Renal Impairment: In patients with a creatinine clearance of 9 to 59 mL/min, an increase in exposure of galantamine was observed; therefore, a dosage adjustment is recommended. Use of ZUNVEYL in patients with creatinine clearance less than 9 mL/min is not recommended.

    For more information about ZUNVEYL, please see the full Prescribing Information here.