Out-of-Pocket Assistance Program Enrollment

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.