Access information is available that may help your patients get started on
If you are considering
Complete the Prescription and Enrollment Form for
When completing the Prescription and Enrollment Form, make sure to provide:
If the patient or their Legal Representative is unable to sign the Prescription and Enrollment Form, PANTHERx Rare Pharmacy will help obtain a signed Patient Authorization Form. This form is also available to patients on the patient website.
See the Healthcare Provider Disclaimer below.
By providing your information and information about your patient on the front of this Prescription and Enrollment Form, you are requesting to participate in PANTHERx Rare Pharmacy (PANTHERx) support for
Patient insurance benefit investigation is provided by PANTHERx. PANTHERx provides assistance in determining whether treatment can be covered by the payer based on the payer’s health plan guidelines and the patient information you provided as authorized by the patient on the Prescription and Enrollment Form, following your determination of medical necessity. Patient out-of-pocket cost support through the Out-of-Pocket Assistance Program for
Verification of insurance coverage is ultimately the responsibility of the provider. Since reimbursement by payers is subject to many factors, PANTHERx and Mitsubishi Tanabe Pharma America do not represent or guarantee that payer reimbursement or any other payment or reimbursement of any kind will be made. PANTHERx and Mitsubishi Tanabe Pharma America do not reimburse for claims denied by payers. Information provided as a result of the benefit investigation is provided for general reference and informational purposes only. PANTHERx makes every effort to be accurate in the information provided; however, no representations or warranties are expressed or implied by PANTHERx and Mitsubishi Tanabe Pharma America regarding the accuracy or reliability of the information. PANTHERx or Mitsubishi Tanabe Pharma America, or its agents or employees shall not be liable legally, financially, or otherwise, for damages of any kind as a result of or related to these services. Providers and other users of this information resulting from benefit investigation services accept full responsibility for use of the service.
Mitsubishi Tanabe Pharma America does not assume responsibility for, nor does it guarantee the availability, scope, or quality of the services offered including reimbursement support, prescription fulfillment coordination, and other services under PANTHERx. Providers, not Mitsubishi Tanabe Pharma America, are responsible for the services they provide. PANTHERx services have no value apart from the product.
To find out more about available access information and if your patient may be eligible for the Out-of-Pocket Assistance Program for
*Restrictions apply. See the.
Eligibility Requirements & Terms and Conditions for the Out-of-Pocket Assistance Program for
Mitsubishi Tanabe Pharma America, Inc. is committed to advancing treatment options for people living with ALS.
Important Safety Information
Warnings and Precautions
The use of
Interstitial Lung Disease
The most common adverse reactions (incidence greater than or equal to 5% and greater than placebo) of
Use in Specific Populations
Based on animal data, riluzole may cause fetal harm. Women should be advised of a possible risk to the fetus associated with use of
Japanese patients are more likely to have higher riluzole concentrations, and thus may be at a greater risk of adverse reactions.
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
Please see the full
Prescribing Information for