Example Treatment Initiation Checklist for RADICAVA ORS®.
Download
Starting RADICAVA ORS® or RADICAVA® IV
This page organizes the process for starting patients on treatment into these steps:
Actor portrayals.
Use These Checklists to Better Understand the Steps for Initiating Treatment.
Example Treatment Initiation Checklist for RADICAVA® IV.
DownloadStep 1 of 3
The Benefit Investigation and Enrollment Form (BIF)
When you are considering starting a patient on RADICAVA ORS® or RADICAVA® IV, it is important to begin with the Benefit Investigation and Enrollment Form (BIF) as soon as possible, as it begins the investigation into your patient's insurance coverage.
When completing the BIF, be sure to provide:
Patient and your office information
Proper insurance information or a copy of your patient's insurance card(s)
Prescription information for RADICAVA ORS® or RADICAVA® IV
Your signature and date of prescription
Patient authorization with a signature from patient or their Legal Representative
The BIF can be completed 2 waysa (see footnote)
Online via eSign
You may complete, sign, and submit the enrollment form online to the JourneyMate Support Program™.
Access the BIF at www.RadicavaOnlineEnrollmentForm.com
Follow instructions for completing, signing, and submitting the online form.
By Mail or Fax
If you have access to a printer, you may submit a completed and signed BIF to the JourneyMate Support Program™ via mail, fax, or electronic fax.
Download and save the editable BIF
Print, sign, scan or photograph, and submit the completed form using:
Mail:
JourneyMate Support Program™
Insurance & Access Specialist
680 Century Point
Lake Mary, FL 32746
Fax:
1-888-782-6157
Completing the BIF also enrolls your patient in the JourneyMate Support Program™b (see footnote)
NOTE: As a reminder, all covered entities are obligated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to have a business associate agreement (BAA) in place with any service provider that handles protected health information (PHI) on their behalf. This includes, among others, electronic data transmission services such as eSign and electronic fax services. Please refer to each service provider's website for more information regarding BAAs and PHI.
Restrictions apply. See Healthcare Provider Disclaimer.
The JourneyMate Support Program™
Gives patients the understanding, answers, and resources to help them move forward.
Once you have prescribed RADICAVA ORS® or RADICAVA® IV and submitted a Benefit Investigation and Enrollment Form (BIF) to check how your patient's health insurance covers treatment, an Insurance & Access Specialistc (see footnote) will reach out to the patient to help them understand the insurance and site of care selection process, if applicable.
An Insurance & Access Specialist will:
Help investigate a patient's health insurance coverage and health plan benefits, as well as the RADICAVA® financial support options which may be available to patients if they meet all eligibility criteria
Help patients understand how to access their prescribed medication, whether it is:
RADICAVA ORS® from a specialty pharmacy; or
RADICAVA® IV from an infusion therapy provider
Also be available throughout the patient's treatment journey to help answer insurance and access-related questions
For questions about the resources available for your patients and your practice, call an Insurance & Access Specialist at 1-844-772-4548.
Patients May Start with the Patient Authorization Form
If a patient or their Legal Representative is not available to sign the BIF, the patient or their Legal Representative has options for submitting a signed Patient Authorization Form:
An Insurance & Access Specialist can email the patient or their Legal Representative a link to the eSign Patient Authorization Form to complete and submit.
The patient or their Legal Representative can download, complete, and sign the Patient Authorization Form available at radicava.com and submit by fax or USPS mail. Learn more.
An Insurance & Access Specialist can mail the patient or their Legal Representative a copy of the Patient Authorization Form to return by fax or USPS mail.
Benefit Summary
After the BIF is submitted, an Insurance & Access Specialist will provide your office with a preliminary Benefit Summary, typically within 2 business days. For the most up-to-date information, you can contact an Insurance & Access Specialist at any time to determine the status of the benefit investigation for your patients.
Information included in a Benefit Summary
For RADICAVA ORS®
Pharmacy Coverage Detail
Primary/Secondary plan coverage information
Prior authorization requirements
Deductible, out-of-pocket maximum, and patient co-pay/co-insurance
Supporting documentation requirements
Specialty pharmacy information
Medicare Part D Pharmacy Coverage Detail
Payer/plan name information
Specialty pharmacy information
Year-to-date out-of-pocket phase status; deductible, initial coverage limit, coverage gap, catastrophic
For RADICAVA® IV
Medical Coverage Detail
Primary/Secondary/Tertiary plan coverage information
Prior Authorization requirements
Deductible, out-of-pocket maximum, and patient co-pay/co-insurance
Supporting documentation requirements
Medication procurement options
Coding requirements
Pharmacy Coverage Detail
Primary/Secondary plan coverage information, as applicable (the information above plus pharmacy-specific benefits verification)
Specialty pharmacy preferences
Medicare Part D Pharmacy Coverage Detail
Payer/plan name information
Specialty pharmacy preferences
Year-to-date out-of-pocket phase status; deductible, initial coverage limit, coverage gap, catastrophic
Restrictions apply. See Benefit Summary Disclaimer.
Financial Support Options Overview
Use with your patients to help them navigate financial support options associated with RADICAVA ORS® or RADICAVA® IV that may be available to them. Terms and conditions apply.
Step 2 of 3
Coverage Determination
For RADICAVA ORS®
For patients with commercial coverage, including Medicare Advantage (Part C), or Medicare Part D, Prior Authorization may be required
The Insurance & Access Specialist can assist with limited support for the Prior Authorization and exceptions and appeals processes by:
Researching patient's health plan for Prior Authorization requirements and forms
Monitoring the status of Prior Authorization submission
Notifying your office within 3 weeks prior to Prior Authorization expiration
Restrictions apply. See Prior Authorization Disclaimer.
For RADICAVA® IV
After the enrollment process is complete, an Insurance & Access Specialist will be assigned and may call your patients to help with:
Site of Care and home infusion treatment options
Financial support options
Please select the appropriate insurance coverage for your patient based on their Benefit Summary.
For patients with commercial coverage, including Medicare Advantage (Part C), or Medicare Part D, Prior Authorization is typically required.
Selecting a site of care for infusion treatment options
Work with your patient and their insurance company to select an appropriate site of care for them to receive their RADICAVA® infusions. These include
Home Infusion
(for patients with Medicare Part B Plans this is an option but it is not covered)
Infusion center
Doctor's office
Hospital
Use our ALS Care Locator to help find sites of care that are convenient for them.
You will send a referral to the treating site of care, including fax orders, IV access/line information, and notes as requested by the site of care.
If required, work with the site of care to complete the prior authorization.
Limited exceptions and appeals assistanced (see footnote)
If the Prior Authorization is denied by the patient's health plan, an Insurance & Access Specialist may be able to provide limited assistance.
Sample Letter of Medical Necessity
This letter provides rationale for treatment with RADICAVA ORS® or RADICAVA® IV . It can help when filing appeals.
Download Sample Letter of Medical NecessitySample Exceptions Letter
This letter can be used as part of a coverage determination to make a formal request for an exception when your patients health plan does not cover a treatment or healthcare service.
Download Sample Exceptions LetterSample Appeal Letter
This letter can be used if you want to challenge a coverage or payment decision made by your patient's health plan.
Download Sample Appeal LetterAn Insurance & Access Specialist does not fill out any information that requires the medical judgment of the prescriber, and only the prescriber can determine whether to pursue a Prior Authorization. Determination of Prior Authorization is at the sole discretion of the health plan. An Insurance & Access Specialist and Mitsubishi Tanabe Pharma America, Inc. do not assume responsibility for, nor do they guarantee the approval of a Prior Authorization request.
Step 3 of 3
Getting patients on treatment
Prescription Fulfillment for RADICAVA ORS®
After an Insurance & Access Specialist determines a patient's health plan coverage for RADICAVA ORS®, the Insurance & Access Specialist will refer the patient's prescription to a specialty pharmacy.
Shortly after receiving the Benefit Investigation and Enrollment Form, the Insurance & Access Specialistc (see footnote) will reach out and let you know what's needed to get started.
The Insurance & Access Specialist is ready to:
- Investigate your patient's health insurance coverage for RADICAVA ORS®
- Send you and your patient a summary of the health insurance benefits for RADICAVA ORS®
- Help patients understand the insurance process and financial support options, if eligible
- Review how patients will receive RADICAVA ORS® from a specialty pharmacy if coverage is approved
RADICAVA ORS® is available from a select network of specialty pharmacies.
With coverage approval from the patient's health plan, the specialty pharmacy will:
- Process the patient's RADICAVA ORS® prescription
- Contact the patient to arrange for payment of out-of-pocket costs, including applying any financial support that may be available to them, if eligible
- Contact the patient or their caregiver to review their prescription details and shipment information
- Ship the medication to the mailing address the patient has provided
Ordering RADICAVA® IV
After you have completed the BIF, your patient will be enrolled in the JourneyMate Support Program™ and a Patient ID will be assigned. You may place all subsequent orders for RADICAVA® IV using their Patient ID to complete the Order Form for Buy and Bill.
Mail:
JourneyMate Support Program™
Insurance & Access Specialist
680 Century Point
Lake Mary, FL 32746
Fax:
1-888-782-6157
For questions about ordering RADICAVA® IV, call the JourneyMate Support Program™ Insurance & Access Specialist at 1-844-772-4548.
FOR RADICAVA® IV: Scheduling Infusions
The chosen site of care schedules the infusion with your patient. Remind your patients of the importance of staying on therapy and continuing to receive their infusions as prescribed.
Switching patients from one treatment formulation to the other
If you and your patient are considering a switch from one formulation of edaravone to the other:
- Complete, sign, and submit a new Benefit Investigation and Enrollment Form (BIF) with a prescription for RADICAVA ORS® or RADICAVA® IV, with the patient's signature
An Insurance & Access Specialist will:
RADICAVA® IV > RADICAVA ORS®
Investigate the patient's Pharmacy benefits and provide education and information to help with the coverage determination process.
Help the patient understand how they will receive RADICAVA ORS® from a specialty pharmacy.
RADICAVA ORS® > RADICAVA® IV
Investigate the patient’s Medical and Pharmacy benefits and provide information and resources to help with the coverage determination process.
Help the patient understand how they will receive RADICAVA® IV from an infusion provider.
Contact the patient to discuss the results of the coverage determination and provide information about the financial support options that may be available to them, if eligible.
Answer the patient's questions and let them know what is needed at each step in the process as they pursue treatment.
Enroll the patient in the Out-of-Pocket Assistance Program for RADICAVA ORS® or RADICAVA® IV if eligible.
Contact the patient to discuss the results of the coverage determination and provide information about the financial support options that may be available to them, if eligible.
Answer the patient's questions and let them know what is needed at each step in the process as they pursue treatment.
Enroll the patient in the Out-of-Pocket Assistance Program for RADICAVA ORS® or RADICAVA® IV if eligible.
How patients receive their treatment and how it is covered can determine their out-of-pocket costs. If you have prescribed RADICAVA ORS® or RADICAVA® IV to an appropriate patient, it may be important for them to understand their health plan coverage benefits for treatment.
Important note: A patient switching from treatment with one formulation of edaravone to the other, and who remains eligible for the Out-of-Pocket Assistance Program, will continue to use their current Out-of-Pocket Assistance Program personalized information.
For patients who served in the military, see the Getting Started For Veterans page.
aMitsubishi Tanabe Pharma America, Inc. ("MTPA") is not affiliated with any electronic fax service providers (collectively, "service providers"). No fees or remuneration of any kind have been or will be exchanged with any healthcare provider for use of these service providers. Return to content
bA patient cannot be enrolled in the JourneyMate Support Program™ without patient authorization, which can be found on the Benefit Investigation and Enrollment Form, or a separate signed Patient Authorization Form for RADICAVA® on file. In addition, a Benefit Investigation and Enrollment Form must be submitted for each patient for whom treatment with RADICAVA® is requested.
Mention of these service providers does not constitute a referral, recommendation, endorsement of a particular service provider, and similarly, the absence of a service provider's name should not be construed as a negative comment from MTPA about that service provider. MTPA, as well as its employees or agents, shall not be held liable for any damages or harm resulting from any use or reliance on these service providers, and MTPA may modify its policy regarding these service providers at any time without notice. Return to content
cA JourneyMate Support Program™ Insurance & Access Specialist is provided by UBC on behalf of Mitsubishi Tanabe Pharma America, Inc. (MTPA). A JourneyMate Support Program™ Insurance & Access Specialist may provide information obtained from outside sources about a patient's insurance coverage, financial support options, and whether treatment is covered by their health plan. This information does not require a patient or their doctor to use any MTPA product. Because the information provided comes from outside sources, a JourneyMate Support Program™ Insurance & Access Specialist cannot guarantee the information will be accurate or complete. Return to content
dThe JourneyMate Support Program™ does not fill out any information that requires the medical judgment of the prescriber, and only the prescriber can determine whether to pursue a Prior Authorization. Determination of Prior Authorization is at the sole discretion of the health plan. The JourneyMate Support Program™ and Mitsubishi Tanabe Pharma America, Inc. do not assume responsibility for, nor do they guarantee the approval of a Prior Authorization request. Return to content
