Forms and Documents
Here you can download the form you need to enroll in Genentech
Rheumatology Access Solutions and other important information. Please
remember, your doctor also needs to fill out a form to enroll
Start Enrollment With the PAN Form
To get started, fill out a form called the PAN. You can find this form below.
Your doctor also has to fill out a form called the SMN. Once we have both these forms, we can begin working with you and your doctor’s office. You do not have to fill out any information on this form.
Treatment Cost Discussion Guide
This information packet includes:
- Questions to consider asking someone at your
doctor's office after you have been prescribed a Genentech
- Information on how to enroll in
Genentech Rheumatology Access Solutions
- A copy of the PAN form
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
What it Treats
ACTEMRA is a prescription medicine used to treat:
- Adults with moderately to severely active rheumatoid arthritis (RA) after at least one other medicine called a disease modifying antirheumatic drug (DMARD) has been used and did not work well
- Adults with giant cell arteritis (GCA)
- Patients with active polyarticular juvenile idiopathic arthritis (PJIA) 2 years of age and older
- Patients with active systemic juvenile idiopathic arthritis (SJIA) 2 years of age and older
It is not known if ACTEMRA is safe and effective in children with PJIA or SJIA under 2 years of age or in children with conditions other than PJIA or SJIA.
Important Safety Information
ACTEMRA can cause serious side effects
ACTEMRA changes the way your immune system works. This can make you more likely to get infections or make any current infection worse. Some people have died from these infections. Your healthcare provider should test you for TB before starting and during treatment with ACTEMRA.
Do not take ACTEMRA if you are allergic to tocilizumab, or any of the ingredients in ACTEMRA.
ACTEMRA can cause other serious side effects. These include:
Tears (perforation) of the Stomach or Intestines
If you have diverticulitis (inflammation in parts of the large intestine), talk to your healthcare provider before taking ACTEMRA. Some people taking ACTEMRA may develop a hole in the wall of their stomach or intestines (also known as a perforation).
Changes in Blood Test Results
Your healthcare provider should do blood tests before you start receiving ACTEMRA. You should not receive ACTEMRA if your neutrophil and platelet counts are too low or your liver function test levels are too high. These may cause your healthcare provider to stop your ACTEMRA treatment for a time or change your dose.
ACTEMRA may increase your risk of certain cancers by changing the way your immune system works.
Hepatitis B Infection
If you have or are a carrier of the hepatitis B virus (a virus that affects the liver), the virus may become active while you use ACTEMRA. Your healthcare provider may do blood tests before you start treatment with ACTEMRA and while you are using ACTEMRA.
Serious Allergic Reactions
Serious allergic reactions, including death, can happen with ACTEMRA. These reactions can happen with any infusion or injection of ACTEMRA, even if they did not occur with an earlier infusion or injection.
Nervous System Problems
While rare, Multiple Sclerosis has been diagnosed in people who take ACTEMRA.
The most common side effects of ACTEMRA include:
- upper respiratory tract infections (common cold, sinus infections)
- increased blood pressure (hypertension)
- injection site reactions
ACTEMRA & Pregnancy
Tell your healthcare provider if you are planning to become pregnant, are pregnant, plan to breast-feed, or are breast-feeding. If you are pregnant and taking ACTEMRA, join the pregnancy registry. To learn more, call 1-877-311-8972 or talk to your healthcare provider to register.
Tell your healthcare provider if you have any side effects. You may report side effects to FDA at 1-800-FDA-1088. You may also report side effects to Genentech at 1-888-835-2555.