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.
Questions and Considerations to Ask Your Doctor’s Office
This information packet includes:
- A copy of the PAN form
- A list of questions you might have
Someone at your doctor's office might be able to answer these questions after you have been prescribed a Genentech medicine.
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® (tocilizumab) is a prescription medicine used to treat:
- Adults with moderately to severely active rheumatoid arthritis, or RA. ACTEMRA is used after at least one other medicine called a Disease Modifying Anti-Rheumatic Drug (DMARD) has been used and did not work well.
- Adults with giant cell arteritis (GCA).
- People with active polyarticular juvenile idiopathic arthritis (PJIA) age 2 years and above.
- People with active systemic juvenile idiopathic arthritis (SJIA) age 2 years and above.
- People who experience severe or life-threatening CRS following chimeric antigen receptor T cell treatment age 2 years and above.
ACTEMRA is not approved for subcutaneous use in people with SJIA or CRS.
It is not known if ACTEMRA is safe and effective in children with PJIA or SJIA under 2 years of age, in children with CRS under 2 years of age, or in children with conditions other than PJIA, SJIA or CRS.
Important Safety Information
ACTEMRA can cause serious side effects. ACTEMRA changes the way a patient’s immune system works. This can make a patient more likely to get infections or make any current infection worse. Some patients have serious infections while taking ACTEMRA, including tuberculosis (TB), and infections caused by bacteria, fungi, or viruses that can spread throughout the body. Some patients taking ACTEMRA have died from these infections.
ACTEMRA can cause other serious side effects. These include:
- Stomach tears
- Changes in blood test results, including low neutrophil (white blood cells) and platelet (platelets help the blood to clot) counts, and increases in certain liver function test levels and blood cholesterol levels
- An increased risk of certain cancers by changing the way a patient’s immune system works
- Hepatitis b infection in people who carry the virus in their blood
- Serious allergic reactions, including death. These may happen with ACTEMRA infusions or injections, even if they did not occur with an earlier infusion or injection. If a patient has had hives, a rash, or experienced flushing after injecting, the patient should tell their doctor or nurse before their next injection
- Nervous system problems
ACTEMRA affects the immune system and may increase a patient’s risk of certain cancers.
Most common side effects in patients treated with ACTEMRA:
Patients must tell their doctor if they have these or any other side effect that bothers them or does not go away:
- Upper respiratory tract infections (like common cold and sinus infections)
- Increased blood pressure (also called hypertension)
- Injection site reactions (for subcutaneous use only)
ACTEMRA & pregnancy:
Patients must tell their doctor if they are planning to become pregnant, are pregnant, plan to breast-feed, or are breast-feeding. The patient and their doctor should decide if the patient will take ACTEMRA or breast-feed. Patients should not do both. If a patient is pregnant and taking ACTEMRA, they must join the pregnancy registry. To learn more, patients should call 1-877-311-8972 or talk to their doctor to register.
Patients must tell their doctor right away if they are experiencing any side effects.
Report side effects to the FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. Call Genentech at 1-888-835-2555.
Please see the full Prescribing Information, including BOXED WARNING and Medication Guide, for additional Important Safety Information.