ACTEMRA Coverage

Benefits Investigations

Genentech Rheumatology Access Solutions can conduct a benefits investigation (BI) to help you determine if a Genentech medicine is covered, if prior authorizations (PAs) are required, which specialty pharmacy (SP) the health insurance plan prefers and if patient assistance might be needed.

Potential outcomes of a BI:

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

A BI may be initiated once the SMN and PAN are submitted to Genentech Rheumatology Access Solutions.

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

The completion and submission of coverage- or reimbursement-related documentation are the responsibility of the patient and health care provider. Genentech makes no representation or guarantee concerning coverage or reimbursement for any service or item.

Prior Authorization

Genentech Rheumatology Access Solutions can help you identify if a prior authorization (PA) is necessary and offer resources as you obtain it for your patient. PA support may be provided once the SMN and PAN are submitted to Genentech Rheumatology Access Solutions.

If your patient’s request for a PA is not granted, your Immunology Field Reimbursement Manager (IFRM) or Genentech Rheumatology Access Solutions Specialist can work with you to determine your next steps. You can find more tips like this in Forms and Documents.

The completion and submission of coverage- or reimbursement-related documentation are the responsibility of the patient and health care provider. Genentech makes no representation or guarantee concerning coverage or reimbursement for any service or item.

RSVP for ACTEMRA for Intravenous (IV) Infusion

When a medical treatment is authorized for a limited period of time, it will generally require reverification for coverage of continued treatment. Genentech Rheumatology Access Solutions can help you obtain reverification for your patients.

Each year, you will receive a list of the ACTEMRA patients you have referred to Genentech Rheumatology Access Solutions. You must review and select the patients for whom you wish to have a BI completed and send the list back to us. If you do not wish to use this service, you may opt out by checking the box on the enrollment form or by calling us directly.

You can download the enrollment form from Forms and Documents.

ACT Fast Program

With the ACT Fast Program, eligible patients taking ACTEMRA may receive free medicine while awaiting an insurance coverage determination.

If you think your patient qualifies for the ACT Fast Program submit the completed SMN and PAN 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.

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.