Getting patients started with EXSERVAN™ (riluzole) oral film

Getting patients started with EXSERVAN™

Access information is available that may help your patients get started on EXSERVAN™ with benefit investigation of patient health insurance benefits for EXSERVAN™.

Begin with the Prescription and Enrollment Form for EXSERVAN™.

If you are considering EXSERVAN™ for your patient, begin by completing the Prescription and Enrollment Form for EXSERVAN™.

EXSERVAN™ Prescription Enrollment Form

Complete the Prescription and Enrollment Form for EXSERVAN™

  1. Download and save the fillable form
  2. Fax the completed form to PANTHERx Rare Pharmacy at 1-855-905-5938.

When completing the Prescription and Enrollment Form, make sure to provide:

  • Prescriber office information
  • Appropriate clinical information, if needed
  • Patient insurance information
  • Your signature
    • – A valid prescriber signature is required to allow PANTHERx Rare Pharmacy to contact the patient
  • Patient or Legal Representative signature

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 EXSERVAN™ (riluzole) oral film. The information you provide will only be used by Mitsubishi Tanabe Pharma America, Inc. (“Mitsubishi Tanabe Pharma America”), our affiliates, and our service providers involved in managing and delivering these services and programs. You may withdraw your request for these services at any time by calling 1-855-743-9275. You agree to be contacted by Mitsubishi Tanabe Pharma America at PANTHERx by mail, fax, or telephone for the purposes of managing and delivering these services and programs. Our Privacy Policy, available at mt-pharma-america.com/privacy-policy, governs the use of the information you provide. By providing the information on this form and submitting this form, you indicate that you have read, understand, and agree to these terms and agree to receive program-related communications from PANTHERx. Please contact PANTHERx at 1-855-743-9275 if you wish to change your communication preferences.

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 EXSERVAN™ is provided to eligible patients as a service by PANTHERx under contract for Mitsubishi Tanabe Pharma America.

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.

Access Information About EXSERVAN™

Woman wearing headset offering assistance on EXSERVAN™

Access information is available to help patients access EXSERVAN™. Other resources include a Sample Letter of Medical Necessity, Sample Exceptions Letter, and Sample Appeal Letter.

To find out more about available access information and if your patient may be eligible for the Out-of-Pocket Assistance Program for EXSERVAN™*, see the Guide to Patient Access.

*Restrictions apply. See the Out-of-Pocket Assistance Program for EXSERVAN™ Terms and Conditions.

Eligibility Requirements & Terms and Conditions for the Out-of-Pocket Assistance Program for EXSERVAN™ (riluzole) oral film

  • This offer may not be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription.
  • Patient must be a citizen or a permanent resident of the US or its territories and reside in the US or its territories where co-pay assistance is not prohibited. Offer good only in the US and its territories.
  • Patient must be 18 to 64 years of age and not enrolled in Medicare.
  • Patient must not be enrolled in government health insurance (ie, Medicare, Medicaid, VA, DoD, or other federal or state assistance programs). If patient moves or switches from commercial insurance to any government health insurance, patient will no longer be eligible.
  • This Program is not valid in states where prohibited by law, taxed, or otherwise restricted.
  • Patient is being treated as an outpatient by a licensed healthcare provider in the US who has prescribed EXSERVAN™ (riluzole) oral film for the patient.
  • Patient currently has private, commercial health insurance with prescription coverage for EXSERVAN™ medication, and patient’s insurance does not cover the entire cost of EXSERVAN™.
  • There is no income requirement.
  • Patient must re-enroll annually to remain in the Program. To re-enroll, reverification of patient insurance benefits is required to confirm that patient continues to meet the eligibility requirements for participation in the Program.
  • Patient is responsible for reporting receipt of co-pay assistance to any insurer, health plan, or other third party who pays for or reimburses any part of the medication cost using the Out-of-Pocket Assistance Program for EXSERVAN™, as may be required.
  • Patient must not seek reimbursement or compensation, in whole or in part, from government health insurance (including Medicare, Medicaid, VA, DoD, or other federal or state assistance programs), a Flexible Spending Account (FSA), a Health Savings Account (HSA), or a Health Reimbursement Account (HRA).
  • Patient will not in any way report or count the value of the product provided under this Program as true out-of-pocket spending (TrOOP) under a Medicare Part D prescription drug benefit.
  • This Out-of-Pocket Assistance Program is not health insurance.
  • This offer is limited to one (1) person during this offering period and is not transferable.
  • No membership fees.
  • This offer is not conditioned on any past, present, or future purchase, including refills.
  • Offer expires December 31, 2021. Mitsubishi Tanabe Pharma America, Inc. has the right to modify, alter, or cancel the Out-of-Pocket Assistance Program for EXSERVAN™ at any time without prior notification.

Access Information Available to Patients

Access information for EXSERVAN™
Access information and resources are available to your patients at EXSERVAN.com

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