RADICAVA ORS

Indicated For

ALS, Amyotrophic Lateral Sclerosis

About This Medication

# RADICAVA ORS Patient Assistance Program: How to Get Edaravone at No Cost ## About RADICAVA ORS (Edaravone) RADICAVA ORS is a prescription medication used to treat amyotrophic lateral sclerosis (ALS). The manufacturer, Mitsubishi Tanabe Pharma America, Inc., offers a Patient Assistance Program through the JourneyMate Support Program to help uninsured patients access this medication at no charge. ## Who Qualifies for This Program You may qualify for the RADICAVA ORS Patient Assistance Program if you meet ALL of the following requirements: - You are uninsured (do not have any health insurance coverage) - You are not covered by government health insurance programs, including Medicare, Medicaid, VA benefits, DoD coverage, or other federal or state assistance programs - Your household income does not exceed 5 times the Federal Poverty Level based on your household size - You have been prescribed RADICAVA ORS by a licensed healthcare provider - You are being treated as an outpatient in the United States ## Income Eligibility Your income must not exceed 5 times the Federal Poverty Level for your household size. The program uses the current Federal Poverty Level guidelines to determine eligibility. For example, if the Federal Poverty Level for a single person is $14,580, you would need to earn no more than $72,900 annually to qualify. | Household Size | Maximum Annual Income (at 5x FPL) | |---|---| | 1 person | Approximately $72,900 | | 2 people | Approximately $98,000 | | 3 people | Approximately $123,100 | | 4 people | Approximately $148,200 | *Note: These figures are estimates based on 2024 Federal Poverty Level guidelines. Actual limits may vary. Contact the program for current income thresholds.* ## Insurance Requirements This program is exclusively for uninsured patients. You cannot qualify if you have: - Private or commercial health insurance - Medicare (including Medicare Part A, B, or D) - Medicaid - Veterans Affairs (VA) coverage - Department of Defense (DoD) coverage - Any other federal or state health insurance assistance program If you have insurance coverage for RADICAVA ORS, you may be eligible for the separate Out-of-Pocket Assistance Program instead, which helps reduce copays and out-of-pocket costs. ## How to Apply: Step-by-Step Process ### Step 1: Complete the Benefit Investigation and Enrollment Form Work with your doctor to complete the Benefit Investigation and Enrollment Form. This form requires: - Your personal and medical information - Your doctor's prescription details for RADICAVA ORS - Your signature and authorization - Your doctor's signature confirming medical necessity ### Step 2: Submit Your Application You and your doctor submit the completed form to the JourneyMate Support Program Insurance & Access Specialist. Your doctor can fax the form to 1-888-782-6157 or mail it to: JourneyMate Support Program 680 Century Point Lake Mary, FL 32746 ### Step 3: Insurance Verification An Insurance & Access Specialist will contact you to verify that you do not have health insurance coverage and to confirm your household size and income information. ### Step 4: Income Verification You will need to provide proof of your total (gross) yearly income. The program will verify your income either: - Electronically through authorized verification services, or - By requesting financial documentation such as: - Most recent federal tax returns - W-2 forms - Recent pay stubs - Other income documentation ### Step 5: Eligibility Determination Once the Insurance & Access Specialist reviews your information and confirms you meet all eligibility requirements, you will be notified of your approval status. ### Step 6: Receive Your Medication If approved, RADICAVA ORS will be provided to you at no charge as prescribed by your doctor. The medication will be shipped directly to you. ## Timeline and Delivery While specific processing timeframes are not published, the program works to process applications efficiently once all required documentation is received. Your doctor's office and the Insurance & Access Specialist will keep you informed of your application status at each step. Once approved, RADICAVA ORS is shipped directly to you. Your doctor will specify the quantity and refill schedule based on your treatment plan. ## Coverage Duration and Reauthorization Once approved, the program will cover RADICAVA ORS at no charge for an initial 12-month period. After your first year, you must reconfirm your eligibility to continue receiving medication through the program. ### Annual Reauthorization Requirements To continue in the program after 12 months, you must: - Provide updated proof of income - Confirm you remain uninsured - Verify you still meet all other eligibility requirements You will be asked to submit: - Most recent federal tax returns - W-2 forms - Recent pay stubs - Other income documentation as requested The program will verify your income electronically or through the documentation you provide. ## What If Your Application Is Denied? If you do not qualify for the Patient Assistance Program, you may have other options: - **Out-of-Pocket Assistance Program**: If you have private commercial health insurance with prescription coverage for RADICAVA ORS, you may qualify for copay assistance to reduce your out-of-pocket costs. - **Discuss with Your Doctor**: Talk with your healthcare provider about alternative treatment options or other resources that may be available. - **Contact the Program**: If you believe you were denied in error, contact the JourneyMate Support Program at 1-844-772-4548 to discuss your situation. ## Important Reminders - This program is only available in the United States - You must remain uninsured to continue receiving assistance - Annual reauthorization is required to maintain eligibility - The program covers the full cost of RADICAVA ORS with no copay or out-of-pocket expense for eligible patients - Your doctor must continue to prescribe RADICAVA ORS for you to receive it through this program ## Contact Information For questions about the RADICAVA ORS Patient Assistance Program or to begin your application: **JourneyMate Support Program** Phone: 1-844-772-4548 Mail: 680 Century Point, Lake Mary, FL 32746 Fax: 1-888-782-6157 Your doctor's office can also help you with questions about the application process. ## Disclaimer This guide provides general information about the RADICAVA ORS Patient Assistance Program. Program eligibility, requirements, and benefits are subject to change. For the most current and complete information, contact the JourneyMate Support Program directly or visit the official RADICAVA website. This information is not a guarantee of program enrollment or medication coverage. All eligibility determinations are made by the program administrator based on individual circumstances and documentation provided.

Program information last verified: March 30, 2026