We can support you and your office staff by providing limited prior authorization assistance, payer policy research for efficient claims submission, general coding and billing information, and support with the exceptions and appeals process.a
Restrictions apply. See
aEach healthcare provider is ultimately
responsible for determining the appropriate codes, coverage, and
payment for individual patients. Searchlight
The BIF can be completed 2 waysc:
Online via DocuSign® PowerForm
You may use a web-enabled DocuSign® PowerForm to complete, sign, and submit a BIF to Searchlight
- Access the BIF at DocuSign®
- Follow instructions for completing, signing, and submitting the DocuSign® PowerForm
By Mail, Fax, or Electronic Fax
If you have access to a printer, you may submit a completed and signed BIF to Searchlight
- Download and save the editable BIF
- Print, sign, scan or photograph, and submit the completed form using:
Patient authorization is required to complete a BIF. Patients can provide this authorization online or via mail, fax, or electronic fax. Learn more about the Patient Authorization form.
NOTE: As a reminder, all covered entities are obligated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to have a business associate agreement (BAA) in place with any service provider that handles protected health information (PHI) on their behalf. This includes, among others, electronic data transmission services such as DocuSign® and electronic fax services. Please refer to each service provider's website for more information regarding BAAs and PHI.
- Acknowledge receipt of the Benefit Investigation and Enrollment Form within 1 business day
- Advise if a prior authorization is required, provide a concise benefit summary to your office and your patient, and offer limited prior authorization and appeals assistance within 2 business days
- Offer streamlined product acquisition options through Buy & Bill (directly from our Limited Distribution Network) or specialty pharmacies (including assignment of medical benefit)
Let your patients know
After the enrollment process is complete, a Care
Coordinator from Searchlight
- Care coordination
Out-of-pocket cost support options,
cMitsubishi Tanabe Pharma America, Inc. ("MTPA") is not affiliated with DocuSign® or any electronic fax service providers (collectively, "service providers"). No fees or remuneration of any kind have been or will be exchanged with any healthcare provider for use of these service providers. Mention of these service providers does not constitute a referral, recommendation, endorsement of a particular service provider, and similarly, the absence of a service provider's name should not be construed as a negative comment from MTPA about that service provider. MTPA, as well as its employees or agents, shall not be held liable for any damages or harm resulting from any use or reliance on these service providers, and MTPA may modify its policy regarding these service providers at any time without notice.
dFollowing receipt of a completed Benefit Investigation and Enrollment Form including all required information.
Restrictions apply. See
The Affordability Options Flashcard is a convenient tool you can use with your patients.
Out-of-Pocket Assistance Program
Support for eligible patients with commercial insurance
Patients who have commercial insurance coverage for treatment with
What eligible patients can expect:
- Savings on their deductible, co-pay, and co-insurance costs for their medication and infusion costs for
- Applicable out-of-pocket costs are covered—up to $20,000 per calendar year
- Patients will be automatically re-enrolled for the next calendar year, if eligible
To share information about the Out-of-Pocket Assistance Program with your patients, please download the Out-of-Pocket Assistance Program Brochure for patients. This information is also available on the RADICAVA.com patient website.
Submitting a claim for reimbursement
Once you have received the primary Explanation of Benefits (EOB) from your patient’s insurance provider, you can submit a claim to the Searchlight
eRestrictions apply. $20,000 maximum program benefit per calendar year per eligibility criteria. See full Eligibility Requirements & Terms and Conditions for details.
Restrictions apply. See
How patients get started in the Program:
The prescriber completes and submits the Benefit Investigation and Enrollment Form. Eligible patients are automatically enrolled in the Program. Patients may also enroll by completing the Out-of-Pocket Assistance Program Enrollment Form available in the patient brochure.
- Verify the patient’s commercial insurance benefits to confirm their eligibility
- Call the patient to explain their insurance benefits for treatment with
RADICAVA®and let them know they are automatically enrolled in the Program
- Send the patient a welcome letter and brochure with a program card
Remind patients to always bring the program card to their treatment appointments.
Patients will provide their program card which contains information required for submission of their request for co-payment assistance.
If the infusion provider cannot or does not participate in the Program, or if the patient has already paid for treatment with
First, send a claim for medication and infusion costs to the patient’s primary health plan. Then, complete a secondary claim request for co-payment assistance and submit it to the Program.
Submit a standard electronic claim to Interactive Medical Systems using Payer ID 56155, Group 00003635, and the patient’s Member ID as a secondary payer.
MAIL OR FAX SUBMISSION
Submit a medical claim form (CMS-1500 or UB-04) and a copy of the primary health plan Explanation of Benefits (EOB).
Mail: PO Box 1349, Wake Forest, NC 27588 Fax: 1-919-562-0021
If submitting a request by fax, please use the Request for Co-payment Assistance Fax Cover Sheet.
Make sure all required procedure and drug codes are clearly stated for treatment with
Payment for applicable out-of-pocket costs will be issued promptly following validation of all required out-of-pocket claim information. You will receive reimbursement for approved out-of-pocket assistance claims the same way you receive primary insurance payments.
The Program will not provide patient reimbursement about the wholesale acquisition cost (WAC) price.
Please note that claims must be submitted within 365 days of the date listed on the EOB received from the patient’s primary insurance company. View complete instructions for submitting a claim for reimbursement.
Submit a request for co-payment assistance for out-of-pocket infusion administration costs as outlined above, including the EOB and the payer invoice. Co-pay funds are not available until the primary payer EOB is submitted as noted above. The patient will submit a claim for out-of-pocket medication costs to the Program.
For help processing a request for co-payment assistance, call
Resources for patients who are uninsured
To share this information with your patients, please download the Patient Assistance Program Brochure. This information is also available on the
gOnly product provided at no charge. The Patient Assistance Program covers only the cost of
Restrictions apply. See
- Complete the Benefit Investigation and Enrollment Form and
submit to Searchlight
Support®with all required documentation.
- If a patient meets the Patient Assistance Program
requirements, the program will cover their
RADICAVA®medication as prescribed by you at no charge for 1 yearh
- Patients must reconfirm their eligibility for continued participation in the program after the initial 12-month eligibility period by providing required financial documentation.
- If a patient continues to meet the program requirements,
they may be able to receive
RADICAVA®at no charge for an additional 12 months.
hOnly the product provided at no charge. The Patient Assistance Program covers only the cost of
The 2020 Open Enrollment Information for Patients brochure is designed to help patients understand coverage options, even if infusion treatments are received at multiple locations, such as your office, infusion centers, a hospital outpatient department, or their homes. During Open Enrollment, patients can review their insurance coverage and make changes, or they can choose new plans. Since this brochure does not include a complete list of health plan options, patients should contact their health insurance companies or go to medicare.gov for specific information.
To help navigate access to treatment with
For questions about the services available for your patients and your practice, call Searchlight
No. However, the Department of Veterans Affairs (VA) provides assistance and access to treatment options for veterans with ALS. This includes treatment with
When you remove
However, if the indicator is blue or purple before the overwrap is opened, it means that the product was exposed to oxygen and should not be used.
Important Safety Information
Sulfite Allergic Reactions
Most Common Adverse Reactions
Most common adverse reactions (at least 10% and greater than placebo) are contusion, gait disturbance, and headache.
Based on animal data,
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
Please see full Prescribing Information.
For more information about