Out-of-Pocket Assistance Program Enrollment

Eligibility Requirements & Terms and Conditions for the Out-of-Pocket Assistance Program for RADICAVA ORS^® (edaravone)

• Patients who meet all eligibility criteria and are enrolled in the Out-of-Pocket Assistance Program may pay as little as $0 per RADICAVA ORS^® prescription dispense, subject to a maximum annual benefit limit of $16,100 per calendar year
• You must currently have private, commercial health insurance with prescription coverage for RADICAVA ORS^®, and your insurance does not cover the entire cost of the medication. Offer is not valid for cash-paying patients
• You are not eligible for RADICAVA ORS^® assistance if you are enrolled in or become enrolled in Medicare Part C (Medicare Advantage), Medicare Part D (prescription drug benefit), Medicaid, Department of Veterans Affairs (VA), Department of Defense (DoD), or any other federal or state health insurance program. Patients enrolled in commercial prescription drug insurance and Medicare Part A (hospital benefit) and/or Medicare Part B (medical benefit) are eligible for assistance so long as they meet all other eligibility criteria
• You may not seek reimbursement or compensation, in whole or in part, from any government health insurance
• By enrolling in the Out-of-Pocket Assistance Program, you agree that the Program is intended solely for the benefit of you as the patient. Some health plans have established programs referred to as "accumulator adjustment" or "co-pay maximizer" programs. An accumulator adjustment program is one in which payments made by you that are subsidized by manufacturer assistance do not count toward your deductibles and other out-of-pocket cost sharing limitations. Co-pay maximizers are programs in which the amount of your out-of-pocket costs is increased to reflect the availability of support offered by a manufacturer assistance program. The Out-of-Pocket Assistance Program is not intended for patients in accumulator or maximizer programs. Mitsubishi Tanabe Pharma America, Inc. reserves the right to modify or discontinue assistance at any time for patients found to be subject to an accumulator adjustment or co-pay maximizer program. You also agree that you are personally responsible for paying any amount of co-pay required after the Out-of-Pocket Assistance Program support is applied
• You must be at least 18 years of age
• 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
• This offer may not be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription
• This Out-of-Pocket Assistance Program is not valid outside the US or in states where prohibited by law, taxed, or otherwise restricted
• You are being treated as an outpatient by a licensed healthcare provider in the US and have been prescribed RADICAVA ORS^® by a licensed healthcare provider
• You must re-enroll annually to remain in the Out-of-Pocket Assistance Program. To re-enroll, reverification of your insurance benefit is required to confirm that you continue to meet the eligibility requirements for participation in the Out-of-Pocket Assistance 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
• Claims must be submitted in a timely manner
• This Out-of-Pocket Assistance Program is not health insurance. 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, 2025. 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