Ordering Radicava

To learn more, call
1-844-SRCHLGT (1-844-772-4548)

At Searchlight Support, we’re here to help you navigate access to treatment with Radicava® (edaravone) for your patients.

Below, you will find instructions and information about some of the forms and processes you may need to complete or review to get patients started on or continue treatment with Radicava®.

Forms for Ordering Radicava

There are 2 options for ordering Radicava®. You can use the Provider Portal or you can download and submit the forms below. To sign in or sign up for the Provider Portal, go here.

Benefit Investigation and Enrollment Form
Learn how to place an initial order for Radicava® and enroll patients in Searchlight Support.

To request a benefit investigation and place an initial order for Radicava® for a patient, you must complete and submit a Benefit Investigation and Enrollment Form.

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 services and 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 copy of patient’s insurance card(s).
  3. Patient Authorization
    Ask patient or their legally authorized representative to read and sign. Provide a copy of Patient Authorization Form to patient. If they are unavailable to sign this from, a Patient Authorization Form may be used.
  4. Patient Financial Information
    Complete patient financial information if patient has no insurance, or no insurance coverage for Radicava®.
  5. Prescriber Information
    Complete prescriber information section to ensure prompt communication with your office.
  6. Prescription Information
    Provide the required prescription information for Radicava®. Check the box if you would like to acquire Radicava® through the specialty pharmacy.a Prescriber signature is required to process patient enrollment and validate prescription.
  7. 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.

Registered users can complete, submit, and track Benefit Investigation and Enrollment Forms on the Searchlight Support Provider Portal. Sign in or sign up for a Provider Portal account >

aIf acquiring Radicava® through the specialty pharmacy provider, Searchlight Support will coordinate assignment of benefits, order placements, and shipping instructions.

Restrictions apply. See Terms and Conditions.

To learn more or get help registering for a secure Provider Portal account, call Searchlight Support at 1-844-SRCHLGT (1-844-772-4548).

Patient Authorization Form
See when this form is needed for Searchlight Support enrollment.

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 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).

Buy and Bill Order Form for Hospital Outpatient Departments and Home Infusion Companies
Learn how to place subsequent orders for Radicava®.

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).

Buy and Bill Order Form for Physician Offices and Infusion Centers
Learn how to place subsequent orders for Radicava®.

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:


Fax Icon
Fax
1-888-782-6157
— OR —
Mail Icon
Mail
Searchlight Support
PO Box 2930
Phoenix, AZ 85062

Registered users can complete, submit, and track Benefit Investigation and Enrollment Forms on the Searchlight Support Provider Portal. Sign in or sign up for a Provider Portal account >

HCP Resources to Access Radicava

The tools and information provided below are available to help you and your office staff access Radicava® for your patients. If you have questions or would like further assistance, call Searchlight Support at 1-844-SRCHLGT (1-844-772-4548).

Getting Started Checklist

Use this list to keep track of the steps you need to take to help your patients access treatment with Radicava®.

Sample Letter of Medical Necessity

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

Final Benefit Summary

See an example of the information you will receive after submitting a Benefit Investigation and Enrollment Form.

View more details about this 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 Terms and Conditions.

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.

See how we can help

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

Registered users can submit requests and monitor the status of PAs on the Searchlight Support Provider Portal. Sign in or sign up for a Provider Portal account >

Restrictions apply. See Terms and Conditions.

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


For questions about ordering, forms, or registering for a secure Provider Portal Account, call 1-844-SRCHLGT (1-844-772-4548).

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.