Forms and Documents
Here you can download the form you need to enroll in Genentech 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 Rituxan
- Information on how to enroll in Genentech 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
What is Rituxan?
Rituxan is a prescription medicine used to treat adults with:
Rheumatoid arthritis (RA): with another prescription medicine called methotrexate, to reduce the signs and symptoms of moderate to severe active RA in adults, after treatment with at least one other medicine called a tumor necrosis factor (TNF) antagonist has been used and did not work well enough.
Granulomatosis with Polyangiitis (GPA) (Wegener’s Granulomatosis) and Microscopic Polyangiitis (MPA): with glucocorticoids.
Pemphigus Vulgaris (PV): to treat moderate to severe PV.
It is not known if Rituxan is safe and effective in children.
Important Safety Information
Important Side Effect Information
What is the most important information I should know about Rituxan?
Rituxan can cause serious side effects that can lead to death, including:
- Infusion Reactions: Infusion reactions are very common side effects of Rituxan treatment. Serious infusion reactions can happen during your infusion or within 24 hours after your infusion of Rituxan. Your healthcare provider should give you medicines before your infusion of Rituxan to decrease your chance of having a severe infusion reaction
- Severe Skin and Mouth Reactions: Tell your healthcare provider or get medical help right away if you get any of these symptoms at any time during your treatment with Rituxan: painful sores or ulcers on your skin, lips, or in your mouth; blisters; peeling skin; rash; or pustules
- Hepatitis B Virus (HBV) Reactivation: If you have had hepatitis B or are a carrier of hepatitis B virus, receiving Rituxan could cause the virus to become an active infection again. Hepatitis B reactivation may cause serious liver problems, including liver failure and death. You should not receive Rituxan if you have active hepatitis B liver disease. Your healthcare provider will monitor you for hepatitis B infection during and for several months after you stop receiving Rituxan
- Progressive Multifocal Leukoencephalopathy (PML): PML is a rare, serious brain infection caused by a virus that can happen in people who receive Rituxan. People with weakened immune systems can get PML. PML can result in death or severe disability. There is no known treatment, prevention, or cure for PML
Before receiving Rituxan, patients should tell their healthcare provider if they:
- have had a severe infusion reaction to Rituxan in the past
- currently have or have a history of other medical conditions, especially heart disease
- have had a severe infection, currently have an infection, or have a weakened immune system
- have had a recent vaccination or are scheduled to receive vaccinations
- have taken Rituxan in the past
- are pregnant or planning to become pregnant. Females who are able to become pregnant should use effective birth control (contraception) during treatment with Rituxan and for 12 months after the last dose of Rituxan
- are breastfeeding or plan to breastfeed. Patients should not breastfeed during treatment and for at least 6 months after the last dose of Rituxan
- are taking any medications, including prescription and over-the-counter medicines, vitamins, and herbal supplements
What are the possible side effects of Rituxan?
Rituxan can cause serious and life‐threatening side effects, including:
- Tumor Lysis Syndrome (TLS): TLS is caused by the fast breakdown of cancer cells. TLS can cause you to have kidney failure and the need for dialysis treatment or may cause an abnormal heart rhythm. Tell your healthcare provider right away if you have any of the following signs or symptoms of TLS: nausea, vomiting, diarrhea, or lack of energy
- Serious Infections: Serious infections can happen during and after treatment with Rituxan and can lead to death. Rituxan can increase you risk of getting infections and can lower the ability of your immune system to fight infections. People with serious infections should not receive Rituxan
- Heart Problems: Rituxan may cause chest pain, irregular heartbeats, and heart attack. Your healthcare provider may monitor your heart during and after treatment with Rituxan if you have symptoms of heart problems or have a history of heart problems
- Kidney Problems: especially if you are receiving Rituxan for non–Hodgkin’s lymphoma (NHL). Your healthcare provider should do blood tests to check how well your kidneys are working
- Stomach and Serious Bowel Problems That Can Sometimes Lead to Death: Tell your healthcare provider right away if you have any stomach-area pain during treatment with Rituxan
What are common side effects during treatment with Rituxan?
The most common side effects of Rituxan include:
- infusion-related reactions
- infections (may include fever, chills)
- body aches
In patients with GPA or MPA, the most common side effects of Rituxan also include:
- low white and red blood cells
- muscle spasms
Other side effects with Rituxan include:
- aching joints during or within hours of receiving an infusion
- more frequent upper respiratory tract infections
These are not all of the possible side effects with Rituxan.
Call your healthcare provider for medical advice about side effects. You may report side effects to the FDA at (800) FDA‐1088 or www.fda.gov/medwatch. You may also report side effects to Genentech at (888) 835‐2555.