ACTEMRA® (tocilizumab) Coverage

Benefits Investigation

Why is a benefits investigation important?

Genentech Rheumatology Access Solutions conducts a benefits investigation (BI) to help you better understand your patient's health insurance plan coverage for the costs associated with treatment. The BI can also determine if a prior authorization (PA) or patient assistance might be needed.

There are 3 possible outcomes of a BI:

  • Treatment is covered
  • PA is required
  • Treatment is denied

To begin with Genentech Rheumatology Access Solutions, you must complete and submit a Statement of Medical Necessity (SMN) form and have your patient complete and submit a Patient Authorization and Notice of Release of Information (PAN) form. To request a BI, be sure to check the appropriate box on the SMN.

The SMN can be submitted online via My Patient Solutions™ or downloaded from Forms and Documents. Be sure to specify on the SMN whether the BI should be done for ACTEMRA intravenous (IV), subcutaneous (SC) or both formulations.

Patients can access the PAN through Forms and Documents or submit the PAN online here.

This description of a BI is for informational purposes only. Genentech Rheumatology Access Solutions makes no representation or guarantee concerning reimbursement or coverage for any service or item.

Prior Authorization

Genentech Rheumatology Access Solutions can help your practice identify if a prior authorization (PA) is needed and offer support as you obtain it for your patient. All we need to begin are a completed and signed Statement of Medical Necessity (SMN) form requesting our assistance with the PA as well as a signed and dated Patient Authorization and Notice of Release of Information (PAN) form.

Genentech Rheumatology Access Solutions can help you as you submit the required PA forms and documentation. If the PA is not granted, Genentech Rheumatology Access Solutions can work with you to determine your next steps. Tips like this can be found in Forms and Documents.
 

RSVP for ACTEMRA for Intravenous (IV) Infusion

RSVP is a streamlined benefits reverification process for ACTEMRA IV patients enrolled in Genentech Rheumatology Access Solutions. The service conducts benefits investigations annually at the start of the plan year for all enrolled patients. You can opt out of this service using the RSVP enrollment form, available in Forms and Documents.

ACT Fast Program

With the ACT Fast Program, eligible patients taking ACTEMRA for subcutaneous (SC) injection may receive treatment while awaiting an insurance coverage determination.

ACT Fast Program eligibility

A patient should be eligible for the ACT Fast Program if the following conditions are met:

  • Patient is taking ACTEMRA SC for an approved indication
  • Patient has not received a coverage decision within 7 days

If you think your patient qualifies for the ACT Fast Program, submit completed SMN and PAN forms to Genentech Rheumatology Access Solutions.

Eligible patients can receive a 14-day supply of ACTEMRA every two weeks for up to 6 months. Once coverage has been determined, the patient no longer qualifies for the ACT Fast Program.