Find the enrollment forms you'll need to help patients access ACTEMRA after it's been prescribed, including for coverage, reimbursement and financial assistance services. There are also tips for composing a letter of medical necessity and appeal letter.
To learn more about the resources available to help your practice, including information on benefits investigations and prior authorizations, go to Helpful Resources for Your Practice.
ACTEMRA Access Solutions can help your patients:
This form is used to collect the patient’s health insurance and treatment information for enrollment in ACTEMRA Access Solutions.
This form is signed and dated by your patient, giving written permission for Genentech to discuss their health information with you and the patient’s health insurance plan.
The Genentech Patient Foundation provides free ACTEMRA to people who don’t have insurance coverage or who have financial concerns and meet eligibility criteria.
The following forms are needed for applying for assistance from the Genentech Patient Foundation:
This form is filled out by the healthcare provider and is used to collect the patient’s treatment information and determine eligibility for free Genentech medicine.
This form is signed and dated by your patient, giving written permission for Genentech to discuss their health information with you and the patient’s health insurance plan.
This guide provides tips to help you draft a letter of medical necessity. A sample letter is also included for your reference.
This guide provides tips to help you draft an appeal letter. A sample letter is also included for your reference.
Use the links below to find additional information to enclose in your letter of medical necessity or appeal letter:
De Benedetti F, et al. N Engl J Med. 2012;367:2385-2395.
De Benedetti F, et al. N Engl J Med. 2012;367:2385-2395.
De Benedetti F, Brunner H, Ruperto N, et al. Efficacy and safety of tocilizumab in patients with systemic juvenile idiopathic arthritis: 2-year data from TENDER, a Phase 3 clinical trial. Presented at the European League Against Rheumatism 2012 in Berlin, Germany; June 6-9, 2012. EULAR Poster #FRI0328.
De Benedetti F, Brunner H, Ruperto N, et al. Efficacy and safety of tocilizumab in patients with systemic juvenile idiopathic arthritis: 2-year data from TENDER, a Phase 3 clinical trial. Presented at the European League Against Rheumatism 2012 in Berlin, Germany; June 6-9, 2012. EULAR Poster #FRI0328.
Data on file. Genentech, Inc.
Data on file. Genentech, Inc.
ACTEMRA [package insert]. South San Francisco, CA: Genentech, Inc.
ACTEMRA [package insert]. South San Francisco, CA: Genentech, Inc.
Brunner H, et al. Identification of optimal subcutaneous doses of tocilizumab in children with systemic juvenile idiopathic arthritis. Presented at the 2018 CARRA Annual Scientific Meeting in Denver, Colorado; April 12-15, 2018. Poster 007.
Brunner H, et al. Identification of optimal subcutaneous doses of tocilizumab in children with systemic juvenile idiopathic arthritis. Presented at the 2018 CARRA Annual Scientific Meeting in Denver, Colorado; April 12-15, 2018. Poster 007.
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