Referrals to the Genentech® Access to Care Foundation (GATCF)
GATCF provides free medicine to eligible patients who are uninsured,
rendered uninsured by payer denial or underinsured. To qualify,
patients must meet financial criteria.
Is My Patient Eligible?
Does your patient have health insurance?
Is your patient’s annual household adjusted gross income (AGI) less than $100,000?
Is your patient’s annual household adjusted gross income (AGI) less than $150,000?
Does your patient spend 5% or more of his or her annual household AGI on the out-of-pocket costs for his or her Genentech medicine?
Your Patient Appears to Be Eligible for GATCF
To get started with GATCF, complete and submit the SMN and PAN to Genentech Rheumatology Access Solutions. Patients must complete Section 6 of the PAN to apply for GATCF.
Your Patient Does Not Appear to Be Eligible for GATCF, but Other Options May Be Available
Several options are available to help eligible patients with the out-of-pocket costs of their Genentech medicines.
Call Genentech Rheumatology Access Solutions at (866) 681‑3261 or use our Patient Assistance Tool to find out which option may be right for your patient.
To be eligible for free Genentech medicine from GATCF, insured
patients must have exhausted all other forms of patient assistance
(including the ACTEMRA Co-pay Card Program and support from
independent co-pay assistance foundations) and meet financial
criteria. Uninsured patients must meet different financial criteria.
Download this flash card to view a summary of GATCF eligibility and
Only the information requested on these forms is required. Providing additional documents or information will delay processing.
Once we receive your patient’s information, Genentech Rheumatology Access Solutions will contact the patient with further instructions. This may include verifying financial eligibility.
PAN=Patient Authorization and Notice of Request
for Transmission of Health Information to Genentech Access Solutions
and Genentech® Access to Care Foundation.
SMN=Statement of Medical Necessity.
Important Safety Information & Indication
ACTEMRA® (tocilizumab) is indicated for the treatment of:
- Adult patients with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response to one or more Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
- Giant cell arteritis (GCA) in adult patients
- Active polyarticular juvenile idiopathic arthritis in patients 2 years of age and older
- Active systemic juvenile idiopathic arthritis in patients 2 years of age and older
- Chimeric antigen receptor (CAR) T cell-induced severe or life-threatening cytokine release syndrome in adults and pediatric patients 2 years of age and older
Important Safety Information
RISK OF SERIOUS INFECTIONS:
Patients treated with ACTEMRA are at increased risk for developing serious infections that may lead to hospitalization or death, including tuberculosis (TB), bacterial, invasive fungal, viral, or other opportunistic infections. If a serious infection develops, interrupt ACTEMRA until the infection is controlled.
Reported infections include:
- Active tuberculosis, which may present with pulmonary or extrapulmonary disease. Patients should be tested for latent tuberculosis before ACTEMRA use and during therapy. Treatment for latent infection should be initiated prior to ACTEMRA use.
- Invasive fungal infections, including candidiasis, aspergillosis, and pneumocystis. Patients with invasive fungal infections may present with disseminated, rather than localized, disease.
- Bacterial, viral and other infections due to opportunistic pathogens.
The risks and benefits of treatment with ACTEMRA should be carefully considered prior to initiating therapy in patients with chronic or recurrent infection.
Patients should be closely monitored for the development of signs and symptoms of infection during and after treatment with ACTEMRA, including the possible development of tuberculosis in patients who tested negative for latent tuberculosis infection prior to initiating therapy.
ACTEMRA is contraindicated in patients with known hypersensitivity to ACTEMRA.
Other serious or potentially life-threatening adverse reactions that have been reported in clinical trials with ACTEMRA include gastrointestinal perforations. Use ACTEMRA with caution in patients who may be at risk for GI perforations.
Laboratory monitoring is recommended due to potential consequences of treatment-related laboratory abnormalities in neutrophils, platelets, lipids, and liver function tests.
ACTEMRA is an immunosuppressant, and treatment with immunosuppressants may result in an increased risk of malignancies.
Hypersensitivity reactions, including anaphylaxis and death, have occurred.
- If anaphylaxis or other hypersensitivity reaction occurs, stop administration of ACTEMRA immediately and discontinue ACTEMRA permanently.
The impact of treatment with ACTEMRA on demyelinating disorders is not known. Monitor patients for signs and symptoms potentially indicative of demyelinating disorders.
Treatment with ACTEMRA is not recommended in patients with active hepatic disease or hepatic impairment.
Avoid use of live vaccines concurrently with ACTEMRA, as clinical safety has not been established.
Most common adverse reactions included upper respiratory tract infections, nasopharyngitis, headache, hypertension, increased ALT, and injection-site reactions (SC only).
You may report side effects to the FDA at (800) FDA-1088 or http://www.fda.gov/medwatch. You may also report side effects to Genentech at (888) 835-2555.
Please see the full Prescribing Information, including BOXED WARNING, for additional Important Safety Information.