Contact info
- Phone
- 1-844-772-4548
- Fax
- 1-888-782-6157
Eligibility
- 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.
- Income limit, single
- 500% of the federal poverty level
- Income limit, couple
- 500% of the federal poverty level
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- No
- US citizenship or residency required
- Yes
Not sure where your income falls? See this year's federal poverty guidelines (opens in a new tab).
Application process
- Documents to attach
- Proof of income
- Prescriber license number
- NPI number
- State license number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Provider and patient
Getting the medication
- Patient receives
- Varies
- Shipped to
- Not published
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- New application every 12 months
- New proof of income every 12 months
Medications covered
- Radicava iv (edaravone iv)
- Radicava ORS (edaravone oral suspension)