Guides and Forms

Get useful tools and resources for your office and patients.

Downloadable Materials


FOR OFFICE
FOR PATIENTS

Getting insurance approval and ordering RADICAVA®

benefit investigation and enrollment form (BIF) for RADICAVA® (edaravone), an FDA approved treatment option for ALS

Benefit Investigation and Enrollment Form (BIF)

Download the BIF to order RADICAVA® and enroll patients in Searchlight Support®. Get more information about this form.

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

Buy and Bill Order Form

Learn how to place subsequent orders for RADICAVA®. Get more information about this form.

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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®.

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patient authorization form for RADICAVA® (edaravone)

Patient Authorization Form

Learn when this form is needed for Searchlight Support® enrollment. Get more information about this form.

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sample letter of medical necessity for RADICAVA® (edaravone)

Sample Letter of Medical Necessity

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

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Insurance and coverage

flashcard for the affordability options for RADICAVA® (edaravone) to help cover applicable out-of-pocket costs

Affordability Options Flashcard

Use with your patients to help them navigate options that may be available to them to help cover applicable out-of-pocket costs associated with RADICAVA® (edaravone).

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RADICAVA® (edaravone) Out-of-Pocket Assistance Program HCP brochure. Eligible patients pay as little as $0 per infusion

Out-of-Pocket Assistance Program Brochure for HCPs

Learn more about the benefits of the Out-of-Pocket Assistance Program for your patients and your office. Get more information about this brochure.

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fax cover sheet to request co-payment assistance for RADICAVA® (edaravone)

Request for Co-payment Assistance Fax Cover Sheet

Use this form if you are submitting a request for co-payment assistance for your patient.

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Product information and administration

modes of infusion leave behind

Modes of Infusion

Learn more about infusing RADICAVA® via a central or peripheral IV device.

brochure outlining how to prepare the infusion bag for RADICAVA® (edaravone)

Preparing the Infusion Bag Flashcard

Download a reminder of the steps to properly prepare the infusion bag.

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prescribing information for RADICAVA® (edaravone)

Prescribing Information

Review the Prescribing Information for RADICAVA®.

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For your patients

2020 open enrollment information for patients brochure

2020 Open Enrollment Information for Patients Brochure

Help patients understand their coverage options. This brochure does not include a complete list of health plan options.

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out of pocket assistance program brochure for ALS patients

Out-of-Pocket Assistance Brochure

Provide information about the Out-of-Pocket Assistance Program for patients with commercial insurance. Get more information about this brochure.

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RADICAVA® (edaravone) patient assistance program brochure

Patient Assistance Program Brochure

Learn about the Searchlight Support® Patient Assistance Program for uninsured patients who are in financial need. Get more information about this brochure.

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patient information for RADICAVA® (edaravone)

Patient Information

Provide patients with more information about receiving RADICAVA®.

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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.