OUT-OF-POCKET ASSISTANCE PROGRAM

Transcription

1 OUT-OF-POCKET ASSISTANCE PROGRAM Helping Provide Patients with Affordable Access to RADICAVA (edaravone) IV infusion Please see accompanying full Prescribing Information, including Patient Information, for RADICAVA, also available at

2 Support for Your Patients Searchlight Support is a customer support program to help guide patient access to treatment with out-of-pocket cost support as well as a nurse helpline, and patient site of care coordination for RADICAVA (edaravone) IV infusion. Support for Healthcare Providers Our dedicated care coordinators can help you determine if your patients with commercial insurance coverage are eligible to be enrolled in the Searchlight Support Out-of-Pocket Assistance Program for RADICAVA. The Out-of-Pocket Assistance Program is not valid for patients covered, in whole or in part, by government-funded health insurance such as Medicare, Medicare Part D, or Medicaid. Other restrictions apply. For full terms and conditions, including complete eligibility and restrictions, visit OUT-OF-POCKET COST SUPPORT OPTIONS Co-pay support for eligible patients with commercial insurance Searchlight Support Out-of-Pocket Assistance Program * ELIGIBLE PATIENTS PAY AS LITTLE AS $ 0 PER INFUSION Eligible patients save on their deductible, co-pay and co-insurance for their medication and infusion costs for RADICAVA Up to $0,000 maximum program benefit for applicable out-of-pocket costs for 1 months from the first eligible date of program participation Your patient will be responsible for any out-of-pocket costs above the annual maximum program benefit Searchlight Support will contact your patient annually, before the end of their eligibility period, to re-enroll for continued savings on RADICAVA * Searchlight Support Out-of-Pocket Assistance Program is for eligible patients who have commercial insurance that covers a portion of the medication and administration costs for RADICAVA. Other restrictions apply. For full Eligibility Requirements & Terms and Conditions, please refer to the Searchlight Support Out-of-Pocket Assistance Program patient brochure, or visit 3

3 How to Get Started You and your patient must complete a Benefit Investigation and Enrollment Form, including all required information. Searchlight Support will verify your patient s commercial insurance benefits to determine if your patient is eligible for the Searchlight Support Out-of-Pocket Assistance Program ( OOP Program ). What your patients can expect If eligible, Searchlight Support will call your patient even before the first infusion. A dedicated care coordinator will: Explain your patient s insurance benefits for treatment with RADICAVA (edaravone) IV infusion Offer information about out-of-pocket cost support options, including enrollment in the OOP Program Send your patient a Welcome Letter which includes their unique OOP Patient ID number How to Enroll Your Practice Searchlight Support will send your office the following forms, to be completed one time only, with instructions to register your practice with the OOP Program: IRS W-9 Form Direct Deposit Authorization Form If you would like to receive your reimbursements via electronic funds transfer (EFT) complete the Direct Deposit Authorization Form and include your bank account information. The required Tax Identification Number (TIN) and legal name on the Direct Deposit Authorization Form must match the information on the IRS W-9 Form to ensure out-of-pocket cost reimbursement claim payments are not delayed. If your office does not register for direct deposit, payments will be made by check. NOTE: If your patient has already paid your office for treatment with RADICAVA, ask your patient to contact Searchlight Support for a Patient Reimbursement Form. We will provide your patient with information on how they may receive reimbursement for their applicable out-of-pocket costs. What your office can expect If a patient is eligible for the OOP Program, your office will receive: Detailed instructions for submitting out-of-pocket cost reimbursement claims The unique OOP Patient ID number for each eligible patient - Keep a copy of the OOP Patient ID in your patient s file. You ll need the OOP Patient ID number when submitting out-of-pocket cost reimbursement claims Monitoring your patient s benefits Searchlight Support will notify you when your patient s remaining annual benefit is approaching $1,000. You can monitor your patient s OOP Program account status at the Provider Portal by registering for an online account at For help registering for a secure Provider Portal account, call Searchlight Support at SRCHLGT ( ). A Medical Out-of-Pocket Reimbursement Provider Cover Sheet with a unique bar code for each patient, to use with the out-of-pocket cost reimbursement claim submission for the initial course of 14 infusion treatments 4 5

4 Patient Name: <PATIENT NAME> Patient Date of Birth: <PATIENT DOB> Co-pay ID: <COPAY ID> Your patient has been successfully enrolled in the Searchlight Support Out-of-Pocket Assistance Program ( OOP Program ). You will receive a Welcome Letter which includes instructions for claim submission under a separate cover. Please use this form as a cover sheet with each medical out-of-pocket reimbursement submission for infusion treatments on days Please fax all required documents as outlined in the claim submission instructions to or requests for reimbursement can be mailed to the following address: SEARCHLIGHT SUPPORT PO BOX 930 PHOENIX, AZ 8506 **VERY IMPORTANT Please use this as the cover sheet only so that bar code above is clearly visible** Claims will be processed upon receipt. Please allow 7-10 business days for receipt of payment. BARCODE If you have any questions about the OOP Program, please call SRCHLGT ( ), from 8 AM to 8 PM ET, Monday through Friday. Confidentiality Notice: The information contained in this facsimile may be confidential and legally privileged. It is intended only for use of the individual named. If you are not the intended recipient, you are hereby notified that the disclosure, copying, distribution, or taking of any action in regards to the contents of this fax except its direct delivery to the intended recipient is strictly prohibited. If you have received this fax in error, please notify the sender immediately and destroy this cover sheet along with its contents, and delete from your system, if applicable. Searchlight Support and the Searchlight Support logo are trademarks of MT Pharma America, Inc. RADICAVA is a trademark of Mitsubishi Tanabe Pharma Corporation. 017 MT Pharma America, Inc. All rights reserved. US only. CNP-RC-US-0070_H 07/17 How to Request Reimbursement Once your patient and your practice have been successfully enrolled in the OOP Program, follow these steps to obtain reimbursement for applicable patient out-of-pocket costs for treatment with RADICAVA (edaravone) IV infusion. For initial course of 14 infusion treatments with RADICAVA Submitting for reimbursement prior to receipt of the primary Explanation of Benefits (EOB) 1 Searchlight Support will complete a benefit investigation to determine your patient s out-of-pocket costs Complete and submit the following documents to Searchlight Support : For subsequent courses of 10 infusion treatments with RADICAVA Submitting for reimbursement following receipt of the primary Explanation of Benefits (EOB) 1 Submit the following documents to Searchlight Support : Copy of the patient s EOB Completed claim form (Universal, UB-04, or CMS-1500 Claim Form) If an adjustment is required after review of the patient s EOB, the OOP Program will apply or deduct the applicable amount from the reimbursement Allow 7-10 business days for receipt of payment Out-of-Pocket Assistance Program Medical Out-of-Pocket Reimbursement Provider Cover Sheet Submit documents by Fax or Mail. It s your choice: Fax: Mail: Searchlight Support, PO Box 930, Phoenix, AZ Medical Out-of-Pocket Reimbursement Provider Cover Sheet Completed claim form (Universal, UB-04, or CMS-1500 Claim Form) Allow 7-10 business days for receipt of reimbursement* When you receive the patient s EOB for the initial course of 14 infusion treatments, submit a copy for review to Searchlight Support If an adjustment is necessary the OOP Program will apply or deduct the applicable amount from future out-of-pocket cost reimbursement claims Reimbursement for Pharmacy Benefits claims If RADICAVA is covered under your patient s pharmacy benefit, the claim for reimbursement for the medication costs only will be managed by the specialty pharmacy and the OOP Program. Your out-of-pocket cost reimbursement claims for administration costs should be submitted as outlined above. * Program will not provide patient reimbursement above the Wholesale Acquisition Cost (WAC) price. Call Searchlight Support for more information or visit for RADICAVA, located also available in the pocket at of this brochure. 6 7

5 Other health plan coverage options Searchlight Support dedicated care coordinators are ready to reach out to your patients with information about other health plan coverage options. Refer patients to Medicare and Social Security Disability Insurance resources so patients can explore their options with government-funded insurance Offer information about government health plan coverage for RADICAVA for patients who are eligible for government-funded insurance Provide information about alternative sources of financial assistance, including independent foundations for patients with government-funded insurance Resources for patients who are uninsured We can also provide information to your patients about the Searchlight Support Patient Assistance Program (PAP): The PAP can help patients in financial need who are uninsured Patients who meet program requirements may be able to receive medication at no charge for up to two years. Restrictions apply. See full Eligibility Requirements & Terms and Conditions at The Corporate Symbol of Mitsubishi Tanabe Pharma America and RADICAVA and the RADICAVA logo are trademarks of Mitsubishi Tanabe Pharma Corporation. Searchlight Support and the Searchlight Support logo are trademarks of Mitsubishi Tanabe Pharma America, Inc. 017 Mitsubishi Tanabe Pharma America, Inc. All rights reserved. U.S. only. CP-RC-US /17