Accessing Treatment

Find instructions and forms you may need to get patients started on or continue treatment with RADICAVA® (edaravone).

Getting Started

The tools and information provided below are available to assist you and your office staff with accessing RADICAVA® for your patients.


Forms and guides to get patients started

getting started checklist to help ALS patients access RADICAVA® (edaravone), an FDA approved treatment option for ALS

Getting Started Checklist

Use this list to keep track of the steps you need to take to support your patients with accessing treatment with RADICAVA®.

Download
benefit investigation and enrollment form

Benefit Investigation and Enrollment Form (BIF)

This form must be completed to request a benefit investigation and place an initial order for RADICAVA®.

Download

In addition to ordering RADICAVA® and starting the benefit investigation process, this form can enroll your patients in the Searchlight Support® program. Once enrolled, patients will have access to assistance that may be available to them through Searchlight Support®. For eligible patients, this may include out-of-pocket cost support.

Following enrollment of your patient and assignment of a Searchlight Support® Patient ID, you may use an Order Form for Buy & Bill to place subsequent orders for RADICAVA® using the Patient ID.

Follow these steps to complete a Benefit Investigation and Enrollment Form:

  1. Patient Information

    Complete the required patient information for Searchlight Support®.

  2. Insurance Information

    Provide proper insurance information or a copy of the patient’s insurance card(s).

  3. Patient Authorization

    Ask the patient or their legally authorized representative to read and sign. Provide a copy of Patient Authorization Form to the patient. If they are unavailable to sign this form, a Patient Authorization Form may be used.

  4. Prescriber Office Information

    Complete the prescriber information section to ensure prompt communication with your office.

  5. Physician Signature

    A signature from the prescribing physician is required to process patient enrollment and validate the prescription.

  6. Preferred Site of Infusion

    Indicate preferred site of infusion. Check the box to request infusion site-of-care location assistance and select an option: Primary, Secondary, or Both. Indicate days that apply to each location. Alternatively, provide information for the Primary and Secondary (if applicable) preferred site(s) of infusion. Include facility name, address, contact, and indicate days that apply to each location.

Following receipt of a completed Benefit Investigation and Enrollment Form, including all required information, Searchlight Support® will verify insurance benefits within 2 business days, advise if a prior authorization is required, provide your office with a benefit summary, and call the patient to discuss access and out-of-pocket cost support options.

Restrictions apply. See

patient authorization form for RADICAVA® (edaravone)

Patient Authorization Form

Patients may use this form to authorize Searchlight Support® services.

Download

If a patient or their legally authorized representative is not available to sign a Benefit Investigation and Enrollment Form, they may authorize Searchlight Support® services by submitting a Patient Authorization Form instead. This form is also available to patients on the RADICAVA.com patient website.

While patients may receive RADICAVA® without providing this authorization, they will not be able to participate in or receive assistance from Searchlight Support®.

Let patients know that this authorization can be cancelled at any time. It will remain in effect for 5 years from the date of signature, or until a patient is no longer participating in Searchlight Support® services, whichever is sooner. Refer patients to the Patient Authorization Form for full terms and conditions.

For questions about patient authorizations for enrollment in Searchlight Support®, call 1-844-SRCHLGT (1-844-772-4548).

sample letter of medical necessity

Sample Letter of Medical Necessity

This sample letter provides rationale for treatment with RADICAVA®. It can help you strengthen claims for treatment and appeals.

Download

Final benefit summary

After you submit a Benefit Investigation and Enrollment Form and your patient’s insurance benefits have been verified, Searchlight Support® will provide your office with a comprehensive Final Benefit Summary within 2 business days. Below you will find information that a Final Benefit Summary may include.

Understanding Patient Benefits

Medical Coverage Detail

  • Primary/Secondary/Tertiary plan coverage information
  • Prior authorization requirements
  • Deductible, out-of-pocket maximum, and patient co-pay/co-insurance
  • Supporting documentation requirements
  • Medication procurement options
  • Coding requirements

Pharmacy Coverage Detail

  • Primary/Secondary plan coverage information, as applicable (the information above plus pharmacy-specific benefits verification)

Medicare Part D Pharmacy Coverage Detail

  • Payer/plan name information
  • Year-to-date out-of-pocket phase status; deductible, initial coverage limit, coverage gap, catastrophic

Restrictions apply. See

To learn more about this summary or see a sample, you may request a visit from a representative or call Searchlight Support® at 1-844-SRCHLGT (1-844-772-4548).


Prior authorization requests

We can assist with limited prior authorization (PA) support.

Our Care Coordinators at Searchlight Support® can help:

  • Research your patient’s health plan for PA requirements and forms
  • Pre-populate the payer’s PA form with the patient’s information
  • Monitor status of the PA submission
  • Notify your office within 3 weeks prior to PA expiration

Restrictions apply. See

For help with PAs, call Searchlight Support® at 1-844-SRCHLGT (1-844-772-4548).

Ordering RADICAVA®

To order RADICAVA®, you can download and submit the forms below.


buy and bill order form to place orders for RADICAVA® (edaravone), an FDA approved treatment option for ALS

Buy and Bill Order Form

Use this form to place subsequent orders for RADICAVA®.

Download

After you have enrolled a patient in Searchlight Support® by completing a Benefit Investigation and Enrollment Form and a Patient ID has been assigned, you may place all subsequent orders for RADICAVA® using the Patient ID to complete an Order Form for Buy & Bill.

For questions about ordering RADICAVA®, call 1-844-SRCHLGT (1-844-772-4548).

You can submit your signed form by:

 
grey fax machine
Fax:
1-888-782-6157
— OR —
grey envelope
Mail:
Searchlight Support®
PO Box 2930
Phoenix, AZ 85062
 
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Important Safety Information

Hypersensitivity Reactions

Radicava® (edaravone) is contraindicated in patients with a history of hypersensitivity to edaravone or any of the inactive ingredients in Radicava®. Hypersensitivity reactions (redness, wheals, and erythema multiforme) and cases of anaphylaxis (urticaria, decreased blood pressure, and dyspnea) have been reported. Patients should be monitored carefully for hypersensitivity reactions, and if they occur, discontinue Radicava®, treat per standard of care, and monitor until the condition resolves.

Sulfite Allergic Reactions

Radicava® contains sodium bisulfite, and may cause allergic type reactions, including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown, but occurs more frequently in asthmatic people.

Most Common Adverse Reactions

Most common adverse reactions (at least 10% and greater than placebo) are contusion, gait disturbance, and headache.

Pregnancy

Based on animal data, Radicava® may cause fetal harm.

Geriatric Use

No overall differences in safety or effectiveness were observed between patients 65 years of age and older and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

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 www.fda.gov/medwatch.

Indication

Radicava® is indicated for the treatment of amyotrophic lateral sclerosis (ALS).

Please see full Prescribing Information.

For more information about RADICAVA®, call 1-888-292-0058.