The type of assistance available varies based on certain criteria including but not limited to your household income and your insurance status. To receive assistance from this Patient Assistance & Support Program, you must complete and submit this application form in its entirety and meet program eligibility requirements.Once you have submitted your application, a representative from Akili Assist® will reach out to you with next steps.

If you have any questions while submitting the application, please call the program at 1-855-977-0975 Option 3. We are available to answer your calls Monday through Friday, from 9AM to 9PM Eastern Time.

As an alternative to the application below, you can complete an editable PDF here and send it in via the instructions on the form.

Please ensure you have a valid prescription for EndeavorRx before completing this application.

Patient Assistance Program Application

Please fill out all fields

Patient Personal Information
Parent/Legal Guardian Financial Information
Please Enter The Total Combined Income For You, Your Spouse, And Your Dependents (Annually):
Insurance information
For each policy you have that provides coverage for the patient, please attach a copy of both sides
of your insurance card and fill in the following:
Primary Insurance
Upload Front Here
Upload Back Here
Secondary Insurance (If Applicable)
Upload Front Here
Upload Back Here
*File types accepted: .png, .jpeg, .pdf. Max file size 5MB
Patient Authorization

I certify that the information I have provided in this form is accurate and complete. I authorize Phil Pharmacy and Akili Interactive Labs, Inc. to use my information to determine eligibility for financial assistance or as otherwise permitted by law. Submission of this form does not constitute approval or guarantee eligibly to receive discounted services. The guidelines for providing hardship assistance may change or the program may be discontinued without notice.


By submitting this form, you consent to Phil pharmacy processing your and/or your child’s data or personal information in accordance with Phil’s Privacy Policy and Phil’s HIPAA Notice, and you agree to the Terms of Use of Akili’s sites.

EndeavorRx:

Indications, Safety and Cautions

Indications:
EndeavorRx is a digital therapeutic indicated to improve attention function as measured by computer-based testing in children ages 8-12 years old with primarily inattentive or combined-type ADHD, who have a demonstrated attention issue. Patients who engage with EndeavorRx demonstrate improvements in a digitally assessed measure, Test of Variables of Attention (TOVA®), of sustained and selective attention and may not display benefits in typical behavioral symptoms, such as hyperactivity. EndeavorRx should be considered for use as part of a therapeutic program that may include clinician-directed therapy, medication, and/or educational programs, which further address symptoms of the disorder.

Safety:
No serious adverse events were reported. Of 538 participants in trials supporting EndeavorRx authorization, 50 participants (9.3%) experienced treatment-related adverse events (probable, likely), and three participants experienced treatment-related adverse events with the digital control, in studies where a control was used. Associated adverse events included frustration (6.1%), headache (1.3%), dizziness (0.6%), emotional reaction (0.4%), nausea (0.4%), and aggression (0.2%). All adverse events were generally transient. Only 3 events led to device discontinuation, and no subject reported lasting or irreversible effects after discontinuation.

Cautions:
Rx only: Federal law restricts this device to sale by or on the order of a licensed health care provider. EndeavorRx should only be used by the patient for whom the prescription was written. For medical questions, please contact your child’s healthcare provider. If you are experiencing a medical emergency, please dial 911. EndeavorRx is not intended to be used as a stand-alone therapeutic and is not a substitution for your child’s medication.

If your child experiences frustration, emotional reaction, dizziness, nausea, headache, eye-strain, or joint pain while playing EndeavorRx pause the treatment. If the problem persists contact your child’s healthcare provider. If your child experiences a seizure stop the treatment and contact your child’s healthcare provider.

EndeavorRx may not be appropriate for patients with photo-sensitive epilepsy, color blindness, or physical limitations that restrict use of a mobile device; parents should consult with their child’s healthcare provider.

Please follow all of your mobile device manufacturer’s instructions for the safe operation of your mobile device. For example, this may include appropriate volume settings, proper battery charging, not operating the device if damaged, and proper device disposal. Contact your mobile device manufacturer for any questions or concerns that pertain to your device.