.png)
Forms and Documents
To enroll your patient in Avastin® Access Solutions, please complete the forms described below. Then fax them to us at (888) 249-4919. Each form is an Adobe® Reader® PDF document. You may type in the form on your computer and print it out, or you may print it out and write in the needed information.
Statement of Medical Necessity (SMN)
The SMN is needed to refer your patient to Avastin Access Solutions and the Genentech® Access to Care Foundation (GATCF). It may also be used to request a prior authorization if you are doing this with Avastin Access Solutions. The physician must sign and date the SMN.
.png)
Patient Authorization and Notice of Release of Information (PAN)
The PAN is a form each patient signs for Avastin Access Solutions or GATCF. The PAN lets Avastin Access Solutions look at your patient's health records. We use this information for the purpose of helping with reimbursement, assisting with appeals or finding other help for eligible patients. The SMN must be faxed with the PAN for processing.
.png)
Fax Cover Sheet
For your convenience, we have provided a fax cover sheet with the contact information already completed. You may use this when you are enrolling a patient in Avastin Access Solutions or GATCF.
Drug Package Insert
Some payers need further documentation to identify Avastin® (bevacizumab). The Avastin Package Insert is one of the documents you can provide to the payer for this purpose.
Sample Claim Form
This sample contains an annotated example of a claim form. It provides information that may be helpful when completing a claim form for Avastin. A claim form is often required when filing a claim with a payer.
Medicare Appointment of Representative (AOR)
The Medicare AOR needs to be completed if you plan to appeal a Medicare decision on behalf of your patient. This form needs to be completed by you and the patient.
Avastin (bevacizumab) Indications and Important Safety Information
Indications
Avastin is a vascular endothelial growth factor-specific angiogenesis inhibitor indicated for the treatment of:
- Metastatic colorectal cancer, with intravenous 5-fluorouracil-based chemotherapy for first- or second-line treatment.
- Non-squamous non-small cell lung cancer, with carboplatin and paclitaxel for first line treatment of unresectable, locally advanced, recurrent or metastatic disease.
- Metastatic breast cancer, with paclitaxel for treatment of patients who have not received chemotherapy for metastatic HER2-negative breast cancer.
- Effectiveness based on improvement in progression-free survival. No data available demonstrating improvement in disease-related symptoms or survival with Avastin.
- Not indicated for disease progression following anthracycline and taxane chemotherapy administered for metastatic disease.
- Glioblastoma, as a single agent for patients with progressive disease following prior therapy.
- Effectiveness based on improvement in objective response rate. No data available demonstrating improvement in disease-related symptoms or survival with Avastin.
- Metastatic renal cell carcinoma with interferon alfa
BOXED Warnings and Additional Important Safety Information
People receiving Avastin may experience side effects. In clinical trials, some people treated with Avastin experienced serious and sometimes fatal side effects, including:
Gastrointestinal (GI) perforation: Treatment with Avastin can result in the development of a potentially serious side effect called GI perforation, which is the development of a hole in the stomach, small intestine, or large intestine. In clinical trials, this event occurred in more people who received Avastin than in the comparison group (0.3% to 2.4%). In some cases, GI perforation resulted in fatality. Avastin therapy should be permanently stopped if GI perforation occurs.
Surgery and wound healing problems: Treatment with Avastin can lead to slow or incomplete wound healing (for example, when a surgical incision has trouble healing or staying closed). In some cases, this event resulted in fatality. Surgery and wound healing problems occurred more often in people who received Avastin than in the comparison group. Avastin therapy should not be started for at least 28 days after surgery and until the surgical wound is fully healed. The length of time between stopping Avastin and having voluntary surgery without the risk of having surgery and wound healing problems has not been determined. Treatment with Avastin should be stopped at least 28 days before voluntary surgery and in people with surgery and wound healing problems that require medical treatment.
Severe bleeding: Treatment with Avastin can result in serious bleeding, including coughing up blood, bleeding in the stomach, vomiting of blood, bleeding in the brain, nosebleeds, and vaginal bleeding. These events occurred up to 5 times more often in people who received Avastin. Across cancer types, 1.2% to 4.6% of people who received Avastin experienced severe to fatal bleeding. People who have recently coughed up blood (greater than or equal to a half teaspoon of red blood) or have serious bleeding should not receive Avastin. Treatment with Avastin should be permanently stopped if serious bleeding occurs (ie, requiring medical attention).
In clinical trials for different cancer types, there were additional serious and sometimes fatal side effects that occurred in more people who received Avastin than in those in the comparison group. The formation of an abnormal passage from parts of the body to another part (non-GI fistula formation) was seen in 0.3% or less of people. Severe to life-threatening stroke or heart problems were seen in 2.4% of people. Too much protein in the urine, which led to kidney problems, was seen in less than 1% of people. Additional serious side effects that occurred in more people who received Avastin than those in the comparison group included severe to life-threatening high blood pressure, which was seen in 5% to 18% of people, and nervous system and vision disturbances (reversible posterior leukoencephalopathy syndrome), which was seen in less than 0.1% of people. Infusion reactions with the first dose of Avastin were uncommon and occurred in less than 3% of people, and severe reactions occurred in 0.2% of people.
Common side effects that occurred in more than 10% of people who received Avastin for different cancer types, and at least twice the rate of the comparison group, were nosebleeds, headache, high blood pressure, inflammation of the nose, too much protein in the urine, taste change, dry skin, rectal bleeding, tear production disorder, back pain, and inflammation of the skin (exfoliative dermatitis). Across all trials, treatment with Avastin was permanently stopped in 8.4% to 21% of people because of side effects.
Avastin may impair fertility. If you are pregnant or thinking of becoming pregnant, talk with your doctor about the potential risk of loss of the pregnancy or the potential risk of Avastin to the fetus during and following Avastin therapy, and the need to continue an effective birth control method for at least 6 months following the last dose of Avastin.
Please see full Product Information, including Boxed WARNINGS, for additional safety information.
Avastin® is a registered trademark and the Access Solutions logo and the Access Solutions Treatment made possible logo are trademarks of Genentech USA, Inc.
