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Guides and Forms

Get useful tools and resources for your office and patients.

Downloadable Materials


FOR OFFICE
FOR PATIENTS

Getting insurance approval and ordering RADICAVA® (edaravone)

Benefit Investigation and Enrollment Form (BIF)

Download the BIF to order RADICAVA® (edaravone) and enroll patients in the JourneyMate Support Program. Learn more about the BIF and how you can now submit it online.

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Order Form for Buy & Bill

Learn how to place subsequent orders for RADICAVA®. Get more information about this form.

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Patient Authorization Form

Learn when this form is needed for JourneyMate Support Program enrollment. Get more information about this form.

Patient authorization is required to complete a BIF. Patients can provide this authorization online or via mail, fax, or electronic fax. Learn more about this form.

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Patient Documentation Checklist

Learn about the El Escorial/Revised Airlie House Diagnostic Criteria for ALS, and the common information used for accessing RADICAVA®.

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Sample Appeal Letter

This letter may be considered if your patient’s coverage is denied because their condition did not meet the plan’s criteria for treatment with RADICAVA®.

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Sample Exceptions Letter

This letter may be considered if your patient’s coverage is denied because RADICAVA® is not on your patient’s health plan formulary, or for another reason.

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Sample Letter of Medical Necessity

This letter provides rationale for treatment with RADICAVA®. It can help you when filing appeals.

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Treatment Initiation Checklist

Use this checklist to facilitate a common understanding of the steps involved in coordinating treatment initiation between the prescribing physician and the infusion site of care. Also includes an insert outlining relevant information typically required for a valid prescription, as well as the 2 ways to submit a prescription with a BIF.

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Insurance and coverage

Financial Support Options Flashcard

Use with your patients to help them navigate options that may be available to them to help cover applicable out-of-pocket costs associated with RADICAVA®.

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Out-of-Pocket Assistance Program Brochure for HCPs

Learn more about the benefits of the Out-of-Pocket Assistance Program for your patients. Get more information about this brochure.

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Product information and administration

Modes of Infusion Brochure

Learn more about infusing RADICAVA® via a central or peripheral IV device.

Preparing the Infusion Bag Flashcard

Download a reminder of the steps to properly prepare the infusion bag.

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Prescribing Information

Review the Prescribing Information for RADICAVA®.

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For your patients

2022 Open Enrollment Information for Patients Brochure

Help patients understand their coverage options. This brochure does not include a complete list of health plan options.

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Out-of-Pocket Assistance Brochure

Provide information about the Out-of-Pocket Assistance Program for eligible patients with commercial insurance. Get more information about this brochure.

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Patient Assistance Program Brochure

Learn about the Patient Assistance Program for uninsured patients who are in financial need. Get more information about this brochure.

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Patient Information

Provide patients with more information about receiving RADICAVA®.

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Understanding Government Health Plan Options Brochure

Provide patients with information about government health plan options that may be available. Get more information about this brochure.

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Important Safety Information

Hypersensitivity Reactions

Radicava® (edaravone) is contraindicated in patients with a history of hypersensitivity to edaravone or any of the inactive ingredients in Radicava®. Hypersensitivity reactions (redness, wheals, and erythema multiforme) and cases of anaphylaxis (urticaria, decreased blood pressure, and dyspnea) have been reported. Patients should be monitored carefully for hypersensitivity reactions, and if they occur, discontinue Radicava®, treat per standard of care, and monitor until the condition resolves.

Sulfite Allergic Reactions

Radicava® contains sodium bisulfite, and may cause allergic type reactions, including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown, but occurs more frequently in asthmatic people.

Most Common Adverse Reactions

Most common adverse reactions (at least 10% and greater than placebo) are contusion, gait disturbance, and headache.

Pregnancy

Based on animal data, Radicava® may cause fetal harm.

Geriatric Use

No overall differences in safety or effectiveness were observed between patients 65 years of age and older and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

To report suspected adverse reactions or product complaints, contact Mitsubishi Tanabe Pharma America, Inc., at 1-888-292-0058. You may also report suspected adverse reactions to the FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

Indication

Radicava® is indicated for the treatment of amyotrophic lateral sclerosis (ALS).

Please see full Prescribing Information.

For more information about RADICAVA®, call 1-888-292-0058.