Forms and Documents
Here you can download the form you need to enroll in Esbriet Access Solutions and other important information. Please remember, your doctor also needs to fill out a form to enroll you.
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 Esbriet
- 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
Esbriet is a prescription medicine used to treat people with a lung disease called idiopathic pulmonary fibrosis (IPF).
It is not known if Esbriet is safe and effective in children.
Select Important Safety Information
Before you take Esbriet, tell your doctor if you:
- have other medical conditions (particularly liver or kidney problems).
- are a smoker.
- are or plan to become pregnant or breastfeed (Esbriet has not been studied in these patients).
- are taking any prescription or over-the-counter medicines, vitamins, or herbal supplements.
What are the possible side effects of Esbriet?
Esbriet may cause serious side effects, including:
- liver problems. Call your doctor if you have symptoms such as yellowing of your skin or eyes, dark or brown urine, pain on the upper right side of your stomach area, bleeding or bruising more easily than normal, or increased fatigue. Your doctor will also do regular blood tests to check your liver.
- sun sensitivity and rash. When you are outside, use sunscreen (SPF 50) and wear a hat and clothes that cover your skin to avoid getting a sunburn.
- stomach problems. Esbriet may cause stomach problems such as nausea, vomiting, diarrhea, indigestion, heartburn, and stomach pain.
Your doctor may change your dose or discontinue Esbriet if side effects do not go away.
The most common side effects of Esbriet include upper respiratory tract infections, feeling tired, headache, dizziness, loss of appetite, sinusitis, insomnia, or weight loss.
These are not all the possible side effects of Esbriet.
What should you avoid while taking Esbriet?
- Direct exposure to sunlight, or light from sunlamps and tanning beds.
- Other medicines that can make your skin sensitive to sunlight.
- Smoking, which may affect how well Esbriet works.
Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088 or www.fda.gov/medwatch or to Genentech at 1-888-835-2555.
Please see full Prescribing Information, including Patient Information, for additional important safety information.