Program Details
Mitsubishi Tanabe Pharma America
JourneyMate Support Program
Radicava ORS
(edaravone oral suspension)
|
| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-844-772-4548 |
Provider Phone: |
|
| Fax: |
1-888-782-6157 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must not have health insurance. Income limits based on FPL.
Patient must not be covered, in whole or in part, by government health insurance, including
Medicare, Medicaid, TRICARE, VA, DoD, or other federal or state assistance programs.
Co-pay assistance is also available.
|
| |
Couple |
|
% FPL |
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
No |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
|
Physician
License #
Required: |
State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
Varies
|
| Shipped To: |
Not Published
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
| Refill Policy: |
Eligible patients can receive product for up to 2 years. |
| Other Information: |
|
|
|
Last Updated: 03/11/2024
www.RxAssist.org
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