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F the U.S. or its territories and reside in the U.S. or its territories. 4. P RESCRIBER INFORMATION (REQUIRED) DIRECTIONS: STARTER DOSE: Once daily 60 mg/200 mL, 60-minute IV infusion for 14 consecutive days, followed by cessation for 14 days MAINTENANCE: Once daily 60 mg/200 mL, 60-minute IV infusion for any 10 of 14 days, followed by cessation for 14 days REFILLS: PRESCRIBER NAME (First, Last) OFFICE CONTACT CITY STATE E-MAIL PHONE FAX MEDICAID/MEDICAR.

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A specialty pharmacy is a state-licensed pharmacy that provides complex medications for patients with serious health conditions. These medications often require extra care in shipping and handling. There are in-network specialty pharmacies to fulfill your prescription for RADICAVA ORS®.

Eligible patients using commercial insurance can save on out-of-pocket medication costs for ®. Depending on the health insurance plan, savings may apply toward co-pay, co-insurance or deductible. Eligible patients pay $5 per injection with a $20,000 maximum program benefit per calendar year.

The Patient Assistance Program allows patients who meet program eligibility requirements to receive RADICAVA ORS® or RADICAVA® IV at no charge for up to two years. 1. You and your doctor complete the Benefit Investigation and Enrollment Form and submit to the JourneyMate Support Program™ Insurance & Access Specialist.

Use this Order Form to order/reorder RADICAVA®. Fax this completed Order Form to 1-888-782-6157 or mail to the JourneyMate Support Program™ Insurance & Access Specialist, 680 Century Point, Lake Mary, FL 32746. For assistance or additional information, call 1-844-772-4548, Monday-Friday, 8:00am-8:00pm ET.

PRESCRIBER INFORMATION(REQUIRED) PRIOR AUTHORIZATION (Please check the appropriate box[es] below to request assistance with prior authorizations) ... PATIENT INFORMATION (REQUIRED) INSURANCE INFORMATION (REQUIRED. ... PREFERRED SITE OF INFUSION (REQUIRED. ... PRIOR MEDICATIONS (REQUIRED. ... CLINICAL INFORMATION (REQUIRED.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232