Once your doctor has prescribed RADICAVA ORS® or RADICAVA® IV and submitted a Benefit Investigation and Enrollment Form (BIF) to check how your health insurance covers treatment, an Insurance & Access Specialist will reach out to help you understand the insurance and site of care selection process. But first, you may want to learn about some of these options below.
Financial Support Options
Help With Navigating Your Options
We understand that serious medical conditions place a financial burden on many families. That's why a JourneyMate Support Program™ Insurance & Access Specialist helps you understand financial support options for RADICAVA ORS® (edaravone) or RADICAVA® IV (edaravone).
Download the Financial Support Options Overview for more information.
Where you receive treatment and how it is covered can determine financial support options. If you have been prescribed RADICAVA ORS® or RADICAVA® IV, it's important to understand your health plan coverage.
Have questions about financial support options?
Call an Insurance & Access Specialist at 1-844-772-4548 Monday through Friday, 8 AM to 8 PM ET.
See how to work with your doctor to start RADICAVA ORS® or RADICAVA® IV?
Out-of-Pocket Assistance Program
Once you've been prescribed RADICAVA ORS® (edaravone) or RADICAVA® (edaravone) IV, ask your healthcare provider if they have or will be submitting a Benefit Investigation and Enrollment Form which includes your signature.a (see footnote) Or you may sign and submit a Patient Authorization Form.
You may also apply by submitting the Out-of-Pocket Assistance Program Enrollment Form. If you meet the eligibility requirements, you may be automatically enrolled in the Out-of-Pocket Assistance Program, which includes:b (see footnote)
Savings on your deductible, co-pay, and co-insurance costs for medication, and infusion costs, if applicablec (see footnote)
Paying as little as $0 per infusion or prescription
Your applicable out-of-pocket costs are covered—up to an annual maximum benefit per patient of $7,500 for RADICAVA ORS® or $20,000 for RADICAVA® IVd (see footnote)
Annual re-enrollment, available upon reverification of commercial insurance benefits to confirm your continued eligibility for the Out-of-Pocket Assistance Program
If eligible, you will receive your personalized information by mail when you are enrolled in the Out-of-Pocket Assistance Program, including:
Your personalized information can be used with your Pharmacy and Medical benefits.
Designed to help you with out-of-pocket costs
For RADICAVA ORS®, your personalized information will be used by a specialty pharmacy to submit reimbursement claims to the Out-of-Pocket Assistance Program
For RADICAVA® IV, make sure to bring your personalized information to all your infusion appointments or use when your home infusion provider requests payment of applicable out-of-pocket costs
Please Note: If your treatment changes from one form of the medication to the other and you remain eligible, you will receive confirmation of your enrollment. Your current Out-of-Pocket Assistance Program personalized information will remain the same.
Here's how you can apply for savings on out-of-pocket costs
At enrollment, the JourneyMate Support Program™ Insurance & Access Specialist wille (see footnote):
Review your insurance benefits to determine out-of-pocket costs and eligibility for the Out-of-Pocket Assistance Program, including verifying commercial insurance
If eligible, send you a welcome letter with your personalized information
Using your personalized information for RADICAVA ORS®
When the specialty pharmacy calls about your prescription:
Your Insurance & Access Specialist will have provided your specialty pharmacy with your personalized information
The specialty pharmacy will use your personalized information to apply the Out-of-Pocket Assistance Program benefit to your applicable out-of-pocket costs
Using your personalized information for RADICAVA® IV
When you receive treatment, an infusion provider will:
Complete and submit a reimbursement claim for your applicable out-of-pocket costs using your personalized information
If the infusion provider does not participate in the Out-of-Pocket Assistance Program, or if you've already paid out-of-pocket costs:
Complete and submit the Request for Out-of-Pocket Assistance Reimbursement Form
Call the Insurance & Access Specialist for assistance, if needed
You may receive a check for applicable out-of-pocket costs following validation of all required claim information.
Information About Government Health Plan Options
If you or your loved one has been diagnosed with amyotrophic lateral sclerosis, there may be government health plan options to consider. A JourneyMate Support Program™ Insurance & Access Specialist can provide general information about those options, including:
Social Security Disability Insurance
Medicare and Medicaid Dual Eligibility
Resources for Patients Who Are Uninsured
You may qualify to participate in the Patient Assistance Program at no charge if you meet these requirements:
You have been prescribed RADICAVA ORS® (edavarone) or RADICAVA® (edavarone) IV
You provide proof of income consisting of all gross income
Your income isn't more than five times the Federal Poverty Level based on household size
You don't have health insurance
You aren't covered, in whole or in part, by government health insurance, including Medicare, Medicaid, TRICARE, VA, DoD, or other federal or state assistance programs
You are a citizen or a permanent resident of the US or its territories, and reside in the US or its territories
You are being treated as an outpatient by a licensed doctor in the US
Federal Poverty Level Guidelines are available here.
How the Patient Assistance Program works
You and your doctor complete the Benefit Investigation and Enrollment Form and submit to a JourneyMate Support Program™ Insurance & Access Specialist.
An Insurance & Access Specialist contacts you to verify that you do not have health insurance coverage, and to qualify you based on your household size and income. If you prequalify:
You income will be verified electronically
OR you will be asked for financial documentation to confirm that you meet all eligibility requirements
If you meet the Patient Assistance Program requirements, the program will cover your RADICAVA ORS® or RADICAVA® IV medication as prescribed by your doctor at no charge for one year.f (see footnote)
You must reconfirm your eligibility for continued participation in the Patient Assistance Program after your initial 12-month eligibility period, by providing proof of income. Income will be verified electronically, or you must submit accurate and complete documentation (eg, most recent federal tax return, W-2, pay stubs) as requested by MTPA each year to validate levels of income.
If you continue to meet the Patient Assistance Program requirements, you may be able to receive RADICAVA ORS® or RADICAVA® IV at no charge for an additional 12 months.
Only product provided at no charge. The Patient Assistance Program covers only the cost of RADICAVA ORS® or RADICAVA® IV and not the cost of any infusion services or healthcare provider visits, which are the sole responsibility of the patient.
Alternate Support/Resource Information
Below, please find some resources that may provide more support for you and your loved ones.
Mitsubishi Tanabe Pharma America, Inc. is not affiliated with these resource organizations, which may have their own eligibility criteria and evaluation processes. By listing these resource organizations, Mitsubishi Tanabe Pharma America, Inc. is not endorsing any particular service or group and is not responsible for the content of these sites or services. These resource organizations are provided here for informational purposes and are not meant to replace your doctor's medical advice.
aYour signature on the Benefit Investigation and Enrollment Form is required to enable automatic enrollment in the Out-of-Pocket Assistance Program. Or you may sign and submit a Patient Authorization Form, available at radicava.com. Return to content
bThe Out-of-Pocket Assistance Program is for eligible patients who have private, commercial health insurance with prescription coverage for RADICAVA ORS® or RADICAVA® IV medication. Not valid for patients covered, in whole or in part, by government health insurance (ie, Medicare, Medicaid, VA, DoD, or other federal or state assistance programs). Other restrictions apply. Return to content
cPersons residing in Massachusetts, Minnesota, Michigan, and Rhode Island are eligible for out-of-pocket assistance for the cost of the drug only and are not eligible for other types of cost support for administration of the medication. Return to content
dYou will be responsible for any costs associated with RADICAVA ORS® or RADICAVA® IV above the annual maximum benefit. Return to content
eAJourneyMate Support Program™ Insurance & Access Specialist is provided by UBC on behalf of Mitsubishi Tanabe Pharma America, Inc. (MTPA). AJourneyMate Support Program™ Insurance & Access Specialist may provide information obtained from outside sources about a patient's insurance coverage, financial support options, and whether treatment is covered by their health plan. This information does not require a patient or their doctor to use any MTPA product. Because the information provided comes from outside sources, a A JourneyMate Support Program™ Insurance & Access Specialist cannot guarantee the information will be accurate or complete. Return to content
fReimbursement claim for your applicable out-of-pocket costs will be submitted by your provider once they receive the EOB from your health plan. Return to content