Out-of-Pocket Assistance Program Enrollment

Please read before proceeding:

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

  • If you meet all eligibility criteria and are enrolled in the Out-of-Pocket Assistance Program you may pay as little as $0 per prescription up to a maximum of $7,500 per patient 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, VA, DoD, or any other federal or state 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.
  • 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 U.S. 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® or RADICAVA® IV 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 benefits 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.
  • 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 12/31/2024. 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.
  • Please visit Radicava.com for more details.

I authorize Mitsubishi Tanabe Pharma America and its partners to communicate with me about this program and my participation in it. I agree to be contacted by mail, email and at the phone number provided. I may opt out at any time by calling 844-772-4548. Mitsubishi Tanabe Pharma America will not sell or rent personally identifiable information as described in the Privacy Policy and can be found at www.radicava.com

The request for enrollment, re-enrollment, or replacement card should be made by the patient or patient representative. To begin please select one of the options below: