Example Treatment Initiation Checklist for RADICAVA ORS® (edaravone).
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® (edaravone) 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
- You may indicate a preferred formulation in Section 3, Prescription Information
- Please check both boxes if you do not have a preference
Your signature and date of prescription
Patient authorization with a signature from patient or their Legal Representative
To help avoid unnecessary delays in patient access to therapy, provide documentation typically required for Prior Authorization.a (see footnote)
The BIF can be completed 2 waysb (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™c (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 Specialistd (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. Fax: 1-888-782-6157.
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 a link to the patient or their Legal Representative to eSign
Mail the form to the patient or their Legal Representative to return by fax or USPS mail
The patient or their Legal Representative can also download, complete, and sign the Patient Authorization Form and submit it by fax or USPS mail.
Download the Steps for Patient Access to Edaravone flashcard that helps you understand how to start a patient on edaravone or switch a patient to their preferred formulation.
Benefit Summary
After the BIF is submitted, an Insurance & Access Specialist will provide your office with a preliminary benefit summary of your patient's health insurance Pharmacy and Medical benefits coverage for RADICAVA ORS® and RADICAVA® IV and indicate the formulation(s) covered by your patient’s health plan. 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.
Step 2 of 3
Coverage Determination
The coverage determination process is based on the formulation of edaravone
For patients with commercial coverage, Medicare Advantage (Part C), or Medicare Part D, Prior Authorization is typically required.
For RADICAVA ORS®
For patients with commercial coverage, Medicare Advantage (Part C), or Medicare Part D, Prior Authorization may be required
The Insurance & Access Specialist provides your office and your patient a preliminary benefit summary, which:
Confirms your patient has health insurance that may cover their RADICAVA ORS® prescription
Determines if your patient’s health insurance specifies a preferred in-network specialty pharmacy
Provides the specialty pharmacy name and contact information to your office and your patient
Assigns a Patient ID number to your patient
Based on the preliminary benefit summary, the prescription is triaged to an in-network specialty pharmacy.
After the specialty pharmacy conducts the final coverage determination and confirms approval of coverage, the Insurance & Access Specialist contacts the patient to discuss financial support options that may be available, if eligible.
Download the Accessing RADICAVA ORS® (edaravone) Through a Specialty Pharmacy flashcard that provides more information about how the specialty pharmacies provide RADICAVA ORS®.
For RADICAVA® IV
After the enrollment process is complete, the dedicated Insurance & Access Specialist is available to help investigate a patient's health insurance coverage and health plan benefits
The prescriber and patient decide on where to receive infusions
The infusion provider submits any additional required information to the patient's health plan
The Insurance & Access Specialist contacts the patient to discuss financial support options that may be available, if eligible
When approval of coverage is confirmed, the infusion provider schedules the patient's treatment with RADICAVA® IV
Restrictions apply. See Prior Authorization Disclaimer.
For RADICAVA® IV
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® IV 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.
If your patient’s preferred formulation is denied by the patient’s health plan, you and your patient may:
Start treatment with the formulation approved by your patient’s health plan
Request an exception from the health plan for coverage of the preferred formulation
If you have been notified that RADICAVA ORS® or RADICAVA® IV is not covered by the patient’s health plan, a helpful guide called Considerations for Understanding Coverage Determination is available through your Mitsubishi Tanabe Pharma America Manager of Patient Access.
Limited exceptions and appeals assistancee (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.
The dedicated Insurance & Access Specialist is ready to help process a script for the preferred formulation when coverage has been determined.
Step 3 of 3
Getting patients on treatment
Prescription Fulfillment for RADICAVA ORS®
With coverage approval from the patient's health plan, the specialty pharmacy completes the prescription process:
Conducts the final coverage determination process
Contacts your patient to discuss insurance coverage
Confirms approval of health plan coverage and coordinates with the Insurance & Access Specialist to provide the final benefit summary to your office and your patient
The Insurance & Access Specialist contacts your patient to discuss financial support options that may be available, including the Out-of-Pocket Assistance Program, if eligible f (see footnote)
Coordinates dispensing the medication to your patient
Applies any financial support options that may be available, if eligible
Processes the prescription
Ships the medication to your patient
For RADICAVA® IV or RADICAVA ORS®: Download the Financial Support Options Overview to help your patients understand the options that may be available to help cover applicable out-of-pocket costs associated with their prescribed RADICAVA® medication.
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.
For patients who served in the military, see the Getting Started For Veterans page.
aMay include, but are not limited to Letter of Medical Necessity, date of diagnosis, functional rating score information, and percent forced vital capacity (%FVC).Return to content
bMitsubishi 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
cA 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
dA 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
eThe 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
f This is not insurance. The Out-of-Pocket Assistance Program is for eligible patients who have commercial insurance that covers a portion of the medication costs for RADICAVA ORS® (edaravone). Support is not valid for patients covered, in whole or in part, by government-funded health insurance such as Medicare, Medicaid, VA, DoD, or other federal or state assistance programs. Other restrictions apply. See full Eligibility Requirements & Terms and Conditions, available at radicavahcp.com Return to content
