About Your Infusion

Eligibility Requirements & Terms and Conditions for the Out-of-Pocket Assistance Program

• This offer may not be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription.
• You must be a citizen or a permanent resident of the US or its territories and reside in the US or its territories where co-pay assistance is not prohibited. Offer good only in the US and its territories.
• You must be 18 to 64 years of age and not enrolled in Medicare.
• You must not be enrolled in government health insurance, (ie, Medicare, Medicaid, VA, DoD, or other federal or state assistance programs). If you move or switch from commercial insurance to any government health insurance, you will no longer be eligible.
• This program is not valid in states where prohibited by law, taxed, or otherwise restricted.
• Persons 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.
• You are being treated as an outpatient by a licensed healthcare provider in the US and have been prescribed RADICAVA® (edaravone) by a licensed healthcare provider.
• You currently have private, commercial health insurance with prescription coverage for RADICAVA® medication, and your insurance does not cover the entire cost of RADICAVA®.
• There is no income requirement.
• You must re-enroll annually to remain in the Program. To re-enroll, reverification of your insurance benefits is required to confirm that you continue to meet the eligibility requirements for participation in the Program.
• You are responsible for reporting receipt of co-pay assistance to any insurer, health plan, or other third party who pays for or reimburses any part of the medication or treatment cost using the Out-of-Pocket Assistance Program, as may be required.
• You must not seek reimbursement or compensation, in whole or in part, from government health insurance (including Medicare, Medicaid, VA, DoD, or other federal or state assistance programs), a Flexible Spending Account (FSA), a Health Savings Account (HSA), or a Health Reimbursement Account (HRA).
• You will not in any way report or count the value of the product provided under this Program as true out-of-pocket spending (TrOOP) under a Medicare Part D prescription drug benefit.
• Claims must be submitted in a timely manner. An EOB from patient’s private, commercial health insurance must be submitted within 365 days of the date of service on the EOB for patient to receive out-of-pocket assistance benefit. No EOB may be submitted more than 90 days after the expiration date of the Out-of-Pocket Assistance Program, and the date of service on the EOB must be prior to the program expiration date. The EOB must reflect the patient’s out-of-pocket cost for RADICAVA® medication and infusion services and submission of the claim by the patient’s physician for the cost of the medication and infusion services.
• This Out-of-Pocket Assistance Program is not health insurance.
• This Out-of-Pocket Assistance Program enables submission of both Pharmacy and Medical benefit claims.
• This offer is limited to one (1) per person during this offering period and is not transferable.
• No membership fees.
• This offer is not conditioned on any past, present, or future purchase, including refills.
• Offer expires December 31, 2022. Mitsubishi Tanabe Pharma America, Inc. has the right to modify, alter, or cancel the Out-of-Pocket Assistance Program at any time without prior notification.

Eligibility Requirements & Terms and Conditions for the Patient Assistance Program for RADICAVA^® (edaravone)

• You must be a citizen or a permanent resident of the US or its territories and reside in the US or its territories.
• You must be between 18 and 65 years of age and not eligible for Medicare.
• You must not be covered, in whole or in part, by government health insurance, (ie, Medicare, Medicaid, VA, DoD, or other federal or state assistance programs).
• You are being treated as an outpatient by a licensed healthcare provider in the US and have been prescribed RADICAVA® by a licensed healthcare provider.
• You must be uninsured (not have health insurance).
• Your income must not exceed five (5) times the Federal Poverty Level based on household size (Federal Poverty Level Guidelines available at https://aspe.hhs.gov/poverty-guidelines).
• Income will be verified electronically, or you must submit accurate and complete documentation (eg, most recent federal tax returns, W-2, pay stubs) as requested by Mitsubishi Tanabe Pharma America, Inc. each year to validate levels of income.
• You and your prescriber may not bill, charge, seek credit for, or otherwise submit any claim for reimbursement for RADICAVA® medication provided through the Patient Assistance Program to any third-party payer.
• Mitsubishi Tanabe Pharma America, Inc. and JourneyMate Support Program™ have the right to verify your eligibility, including the right to audit any information provided on the Benefit Investigation and Enrollment Form, and the right to contact you to confirm receipt of medications.
• Mitsubishi Tanabe Pharma America, Inc. and JourneyMate Support Program™, in their sole discretion, can determine your eligibility to participate in the Patient Assistance Program.
• Approved patients will be eligible to receive assistance for up to two years with reconfirmation of eligibility required following the patient's initial 12 months of participation. The Patient Assistance Program covers only the cost of RADICAVA® and not the cost of any infusion services or healthcare provider visits, which are the sole responsibility of the patient.
• Prior to the end of the initial 12-month eligibility period, you must provide proof of income in order to reconfirm eligibility to continue participation in the program for an additional 12 months.
• JourneyMate Support Program™ will validate continued income and insurance eligibility annually.
• The program requires that you re-enroll every two years by completing a Benefit Investigation and Enrollment Form for RADICAVA® and provide proof of income. A notice regarding re-enrollment will be sent to you 45 days in advance of the expiration of your participation in the program.
• Patients must notify JourneyMate Support Program™ of any changes in their total gross income and/or health insurance status. If you obtain health insurance, you will no longer be eligible to participate in the program.
• Patients who no longer satisfy the eligibility requirements will be immediately withdrawn from the Patient Assistance Program, including patients participating in the Patient Assistance Program who become eligible for Medicare coverage.
• Mitsubishi Tanabe Pharma America, Inc. has the right to modify, alter, or cancel the Patient Assistance Program at any time without prior notification.

JourneyMate Support Program™ can help answer questions about benefits, insurance coverage, out-of-pocket support options, and more. If you have not already done so, you may want to call JourneyMate Support Program™ first at 1-844-SRCHLGT (1-844-772-4548), before submitting your question(s).

Call your healthcare provider for medical advice about side effects. You may report side effects to Mitsubishi Tanabe Pharma America, Inc. at 1-888-292-0058 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

If you have a medical emergency, call 911 or go to the nearest emergency room.