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 about all of your medical conditions, including if you:
- have liver problems.
- have kidney problems.
- are a smoker.
- are pregnant or plan to become pregnant. It is not known if Esbriet will harm your unborn baby.
- are breastfeeding or plan to breastfeed. It is not known if Esbriet passes into your breast milk.
You and your doctor should decide if you will take Esbriet or breastfeed.
Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.
What should I avoid while taking Esbriet?
- Sunlight. Esbriet can make your skin sensitive to the sun and the light from sunlamps and tanning beds. You could get a severe sunburn. Use sunscreen (SPF 50) and wear a hat and clothes that cover your skin if you have to be in sunlight. Talk to your doctor if you get sunburn or a rash.
- Taking Esbriet with other medicines that can make your skin sensitive to the sun, the light from sunlamps and tanning beds.
- Smoking. Smoking may affect how well Esbriet works.
What are the possible side effects of Esbriet?
Esbriet may cause serious side effects, including:
- liver problems. Call your doctor right away if you have unexplained symptoms such as yellowing of your skin or the white part of your eyes (jaundice), dark or brown (tea-colored) urine, pain on the upper right side of your stomach area (abdomen), bleeding or bruising more easily than normal, or feeling tired. Your doctor will do blood tests to check how your liver is working during your treatment with Esbriet.
- sensitivity to sunlight (photosensitivity) and rash. See “What should I avoid while taking Esbriet?”
- stomach problems. Esbriet may cause stomach problems such as nausea, vomiting, diarrhea, indigestion, heartburn, and stomach pain. Tell your doctor right away if your stomach problems get worse or do not go away. Your doctor may need to change your dose of Esbriet.
The most common side effects of Esbriet include feeling tired, insomnia, upper respiratory tract infections, sinusitis, headache, dizziness, decreased weight and decreased or loss of appetite.
These are not all the possible side effects of Esbriet.
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. You may also report side effects to Genentech at 1-888-835-2555.