Forms and Documents

Genentech Rheumatology Access Solutions Enrollment Forms

The SMN and PAN are required for enrollment in Genentech Rheumatology Access Solutions.

Other Important Documents

Considerations for Composing a Letter of Medical Necessity

This guide provides tips to help you draft a letter of medical necessity. A sample letter is also included for your reference. Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for ACTEMRA

 

Considerations for Composing a Sample Appeal Letter

This guide provides tips to help you draft an appeal letter. A sample letter is also included for your reference. Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for ACTEMRA

 

Rheumatology Subsequent Verification Program (RSVP) Enrollment Form

ACTEMRA® (tocilizumab) patients enrolled in Genentech Rheumatology Access Solutions are automatically enrolled in RSVP. Use this form to opt out of this program.

 

Fax Cover Letter

Use this cover sheet when faxing documents to Genentech Rheumatology Access Solutions.

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

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.