Searchlight Support^®

Prior authorization (PA) assistance is limited. Searchlight Support^® does not fill out any information that requires the medical judgment of the prescriber, and only the prescriber can determine whether to pursue a PA.

Each healthcare provider is ultimately responsible for determining the appropriate codes, coverage, and payment for individual patients. Searchlight Support^® does not guarantee third-party coverage or payment for RADICAVA^® or reimburse for claims that are denied by third-party payers.

By providing your information and information about your patient on a Benefit Investigation and Enrollment Form, you are requesting to participate in Searchlight Support^® and its programs. The information you provide will only be used by Mitsubishi Tanabe Pharma America, Inc., our affiliates, and our service providers involved in managing and delivering these services and programs. You may withdraw your request for these services at any time by calling 1-844-772-4548. You agree to be contacted by Mitsubishi Tanabe Pharma America, Inc. at Searchlight Support^® by mail, fax, e-mail, or telephone for the purposes of managing and delivering these services and programs. Our Privacy Policy, available at www.mt-pharma-america.com/privacy-policy , governs the use of the information you provide. By providing the information on this form and submitting this form, you indicate that you have read, understand, and agree to these terms and agree to receive program-related communications from Searchlight Support^® and its service providers, including McKesson Specialty Health (“MSH”), and TrialCard, Inc. (TrialCard). Please contact Searchlight Support^® at 1-844-772-4548 if you wish to change your communication preferences.

Patient insurance benefit investigation is provided as a service by MSH under contract for Mitsubishi Tanabe Pharma America, Inc. MSH provides assistance in determining whether treatment can be covered by the payer based on the payer’s health plan guidelines and the patient information you provided as authorized by the patient on the Benefit Investigation and Enrollment Form, following your determination of medical necessity. Patient out-of-pocket cost support through the Searchlight Support^® Out-of-Pocket Assistance Program is provided to eligible patients as a service by TrialCard under contract for Mitsubishi Tanabe Pharma America, Inc.

Verification of insurance coverage is ultimately the responsibility of the provider. Since reimbursement by payers is subject to many factors, MSH and Mitsubishi Tanabe Pharma America, Inc. do not represent or guarantee that payer reimbursement or any other payment or reimbursement of any kind will be made. MSH and Mitsubishi Tanabe Pharma America, Inc. do not reimburse for claims denied by payers. Information provided as a result of the benefit investigation is provided for general reference and informational purposes only. MSH makes every effort to be accurate in the information provided; however, no representations or warranties are expressed or implied by MSH and Mitsubishi Tanabe Pharma America, Inc. regarding the accuracy or reliability of the information. MSH or Mitsubishi Tanabe Pharma America, Inc., or its agents or employees, shall not be liable legally, financially, or otherwise, or for damages of any kind as a result of or related to these services. Providers and other users of this information resulting from benefit investigation services accept full responsibility for use of the service.

Mitsubishi Tanabe Pharma America, Inc. does not assume responsibility for, nor does it guarantee the availability, scope, or quality of the services offered, including reimbursement support, prescription fulfillment coordination, and other services under Searchlight Support^®. Providers, not Mitsubishi Tanabe Pharma America, Inc., are responsible for the services they provide. The Searchlight Support^® services have no value apart from the product.

• This offer may not be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription.
• Patient must be a citizen or permanent resident of the US or its territories, and reside in the US or its territories where co-pay assistance is not prohibited. Offer good only in the US and its territories.
• Patient must be 18 to 64 years of age and not enrolled in Medicare.
• Patient must not be enrolled in government health insurance, (ie, Medicare, Medicaid, VA, DoD, or other federal or state assistance programs). If patient moves or switches from commercial insurance to any government health insurance, patient will no longer be eligible.
• This program is not valid in states where prohibited by law, taxed, or otherwise restricted.
• Persons residing in Massachusetts, Minnesota, Michigan, and Rhode Island are eligible for out-of-pocket assistance for the cost of the drug only and are not eligible for other types of cost support for administration of the medication.
• Patient is being treated as an outpatient by a licensed healthcare provider in the US and has been prescribed RADICAVA^® (edaravone) by a licensed healthcare provider.
• Patient currently has private, commercial health insurance with prescription coverage for RADICAVA^® medication, and their insurance does not cover the entire cost of RADICAVA^®.
• There is no income requirement.
• Patient will be automatically re-enrolled on December 31 set in subsequent calendar years after the initial enrollment period ends as long as patient continues to meet the eligibility requirements for participation in the Program.
• Patient is responsible for reporting receipt of co-pay assistance to any insurer, health plan, or other third party who pays for or reimburses any part of the medication or treatment cost using the Searchlight Support^® Out-of-Pocket Assistance Program, as may be required.
• Patient must not seek reimbursement or compensation, in whole or in part, from government health insurance (including Medicare, Medicaid, VA, DoD, or other federal or state assistance programs), a Flexible Spending Account (FSA), a Health Savings Account (HSA), or a Health Reimbursement Account (HRA).
• Patient will not in any way report or count the value of the product provided under this Program as true out-of-pocket spending (TrOOP) under Medicare Part D prescription drug benefit.
• Claims must be submitted in a timely manner. An EOB from patient's private, commercial health insurance must be submitted within 365 days of the date of service on the EOB for patient to receive out-of-pocket assistance benefit. No EOB may be submitted more than 90 days after the expiration date of the Out-of-Pocket Assistance Program, and the date of service on the EOB must be prior to the program expiration date. The EOB must reflect the patient's out-of-pocket cost for RADICAVA^® medication and infusion services and submission of the claim by the patient's physician for the cost of the medication and infusion services.
• This Out-of-Pocket Assistance Program is not health insurance.
• This offer is limited to one (1) per person during this offering period and is not transferable.
• No membership fees.
• This offer is not conditioned on any past, present, or future purchase, including refills.
• Offer expires December 31, 2020. Mitsubishi Tanabe Pharma America, Inc. has the right to modify, alter, or cancel the Searchlight Support^® Out-of-Pocket Assistance Program at any time without prior notification.

Searchlight Support^® does not fill out any information that requires the medical judgement of the prescriber, and only the prescriber can determine whether to pursue a prior authorization.

• Patient must be a citizen or permanent resident of the US or its territories, and reside in the US or its territories.
• Patient must be 18 years of age or older, and under the age of 65.
• Patient must not be covered, in whole or in part, by government health insurance, (ie, Medicare, Medicaid, VA, DoD, or other federal or state assistance programs).
• Patient is being treated as an outpatient by a licensed healthcare professional in the US and have been prescribed RADICAVA^® (edaravone) by a licensed healthcare professional.
• Patient must be uninsured (not have health insurance).
• Patient's income must not exceed five (5) times the Federal Poverty Level based on household size (Federal Poverty Level Guidelines available at https://aspe.hhs.gov/poverty-guidelines).
• Patient must submit accurate and complete documentation (eg, most recent federal tax returns, W-2, pay stubs) as requested by Mitsubishi Tanabe Pharma America, Inc., each year to validate levels of income.
• Patient and their prescriber may not bill, charge, seek credit for, or otherwise submit any claim for reimbursement to RADICAVA^® medication provided through the Patient Assistance Program to any third-party payer.
• Mitsubishi Tanabe Pharma America, Inc. and Searchlight Support^® have the right to verify patient's eligibility, including the right to audit any information provided on the Benefit Investigation and Enrollment Form, and the right to contact patients to confirm receipt of medications.
• Mitsubishi Tanabe Pharma America, Inc. and Searchlight Support^®, in their sole discretion, can determine each patient's eligibility to participate in the Searchlight Support^® Patient Assistance Program.
• Approved patients will be eligible to receive assistance for up to two (2) years from the date of enrollment for each enrollment form submitted. The Patient Assistance Program covers only the cost of RADICAVA^® and not the cost of any infusion services or healthcare provider visits, which are the sole responsibility of the patient.
• Prior to the end of the initial 12-month eligibility period, patient must provide proof of income in order to reconfirm eligibility to continue participation in the program for an additional 12 months.
• Searchlight Support^® will validate continued income and insurance eligibility annually.
• The program requires that the patient re-enrolls every two (2) years by completing a Searchlight Support^® Benefit Investigation and Enrollment Form for RADICAVA^® and provides proof of income. A notice regarding re-enrollment will be sent to the patient 45 days in advance of the expiration of participation in the program.
• Patients must notify Searchlight Support^® of any changes in their total gross income and/or health insurance status.
• Patients who no longer satisfy the eligibility requirements will be immediately withdrawn from the Searchlight Support^® Patient Assistance Program, including patients participating in the Searchlight Support^® Patient Assistance Program who become eligible for Medicare coverage.
• Mitsubishi Tanabe Pharma America, Inc. has the right to modify, alter, or cancel the Searchlight Support^® Patient Assistance Program at any time without prior notification.

The information provided in the Final Benefit Summary is based on the information provided by your office on the Benefit Investigation and Enrollment Form. It is not a guarantee of payment and does not take the place of written policy information from the patient's insurance plan.