Once your doctor decides to prescribe EXSERVAN™ (riluzole), you are just a few steps away from receiving your prescription from PANTHERx Rare specialty pharmacy (PANTHERx).
First, you and your doctor will work together to fill out the Prescription and Enrollment Form for EXSERVAN™. The doctor will then submit the form to PANTHERx.
If you are an eligible patient with commercial insurance, signing the Prescription and Enrollment Form before it is submitted will ensure that you will be enrolled in the Out-of-Pocket Assistance Program for EXSERVAN™.
If you can’t sign the Prescription and Enrollment Form, you may complete and sign the Patient Authorization Form for EXSERVAN™ which can then be faxed to PANTHERx at 1-855-905-5938.
After your Prescription and Enrollment Form has been submitted to PANTHERx, they will begin a benefit review. Once the review has been completed, PANTHERx will contact you and your doctor with the results.
Look for a call from 1-855-743-9275. PANTHERx will review your prescription details including your delivery information. They will also talk to you about cost support options, including the Out-of-Pocket Assistance Program for EXSERVAN™ if you are an eligible patient with commercial insurance.
This Information and Resources brochure can help explain the cost and savings support that may be available to you.DOWNLOAD HERE
Mitsubishi Tanabe Pharma America offers educational resources to support access to treatment with EXSERVAN™.
If your health plan denies coverage for EXSERVAN™, this guide can provide general information about requesting an exception.
It’s important to review your insurance options for the upcoming year since it can determine your out-of-pocket costs. Then, during open enrollment, you can make changes to your present plan, or choose a new health plan.
The Open Enrollment Information for Patients brochure* is designed to help you make informed choices during the annual open enrollment period.
If PANTHERx verifies you are covered with commercial insurance, and confirms your eligibility, you will automatically be enrolled in the Out-of-Pocket Assistance Program for EXSERVAN™.†
This program offers savings on your deductible, co-pay, and co-insurance costs for EXSERVAN™.‡
NO SAVINGS CARD NEEDED. Your program benefit will be applied to cover your applicable out-of-pocket costs each time your prescription is filled.‡
If you are eligible for government-funded insurance, general information about government health plan options for EXSERVAN™ is available in the Understanding Government Health Plan Options patient brochure.DOWNLOAD HERE
*Does not include a complete list of health plan options. Please contact your health insurance company or medicare.gov for specific information.
†PANTHERx Rare Pharmacy provides specialty pharmacy services for EXSERVAN™. PANTHERx Rare Pharmacy cannot enroll patients in the Out-of-Pocket Assistance Program for EXSERVAN™ without Patient Authorization, which can be found on the Prescription and Enrollment Form, or a separate signed Patient Authorization form on file.
‡You will be responsible for any costs associated with EXSERVAN™ above the maximum annual program benefit.
Do not use if you are allergic to riluzole or to any of its ingredients.
Before using EXSERVAN™, tell your doctor about all the medicines you take and all your health conditions, including if you:
EXSERVAN™ can cause serious side effects, including:
Liver Problems: Cases of liver injury, some fatal, have occurred in patients taking riluzole. Consult your doctor promptly if you experience unexplained nausea, vomiting, stomach (abdominal) pain, fatigue, weight loss (anorexia), jaundice (yellowing of the skin or whites of the eyes), and/or dark urine.
Low White Blood Cell Counts (Neutropenia): Tell your doctor if you develop a fever while taking EXSERVAN™.
Serious Lung Problems (Interstitial Lung Disease): Tell your doctor if you have problems with your lungs or breathing such as dry cough and difficult or labored breathing. Discontinue EXSERVAN™ immediately if you develop interstitial lung disease.
The most common side effects include numbness in the mouth or tongue, muscle weakness, nausea, lung problems, high blood pressure, and stomach (abdominal) pain.
These are not all the possible side effects of EXSERVAN™. Consult your doctor for medical advice about side effects.
To report side effects, contact Mitsubishi Tanabe Pharma America, Inc. at
Use EXSERVAN™ as prescribed. The recommended dosage for EXSERVAN™ is 50 mg taken orally twice daily at least 1 hour before or 2 hours after a meal. Place EXSERVAN™ oral film strip on the top of the tongue where it will adhere and dissolve. Swallow in a normal manner. Do not cut or split the film or take liquids with EXSERVAN™. Do not chew, spit, or talk while EXSERVAN™ is dissolving. Read the Instructions for Use for EXSERVAN™.
EXSERVAN™ (riluzole) is indicated for the treatment of amyotrophic lateral sclerosis (ALS).
Please click here to see the full Prescribing Information for EXSERVAN™.