Forms and Documents
To enroll your patient in Rituxan® 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 Rituxan 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 Rituxan Access Solutions. The physician must sign and date the SMN.
Patient Authorization and Notice of Release of Information (PAN)
The PAN is a form each patient signs for Rituxan Access Solutions or GATCF. The PAN lets Rituxan 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.
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 Rituxan Access Solutions or GATCF.
Sample Appeal Letter
This Sample Appeal Letter provides you with a template for the approved Rituxan® (rituximab) indication. You may use this when appealing a denial on behalf of your patient.
Medicare Appointment of Representative (AOR)
If your patient would like you to assist with an appeal, Medicare may require this form. This form needs to be completed by you and the patient.
INDICATIONS
RITUXAN® (Rituximab) is indicated for the treatment of patients with:
- Relapsed or refractory, low-grade or follicular, CD20-positive, B-cell NHL as a single agent
- Previously untreated follicular, CD20-positive, B-cell NHL in combination with CVP chemotherapy
- Non-progressing (including stable disease), low-grade, CD20-positive, B-cell NHL, as a single agent, after first-line CVP chemotherapy
- Previously untreated diffuse large B-cell, CD20-positive NHL in combination with CHOP or other anthracycline-based chemotherapy regimens
- Previously untreated CD20-positive CLL in combination with FC chemotherapy
- Previously treated CD20-positive CLL in combination with FC chemotherapy
People with serious infections should not receive RITUXAN
IMPORTANT SAFETY INFORMATION
RITUXAN can cause serious side effects that can lead to death, including: infusion reactions, tumor lysis syndrome (TLS; kidney failure due to fast breakdown of cancer cells), severe skin and mouth reactions, and progressive multifocal leukoencephalopathy (PML; a rare, serious brain infection).
RITUXAN has also been associated with serious and life-threatening side effects, including: the return of active hepatitis B virus infection with sudden and serious liver problems including liver failure, and death, other serious infections that can lead to death, heart problems, kidney problems, and stomach and serious bowel problems including blockage and tears in the bowel that can sometimes lead to death.
The most common side effects of RITUXAN seen in patients with non-Hodgkin's lymphoma were infusion reactions, fever, chills, low white blood cells, infections, body aches, and tiredness. The most common side effects of RITUXAN in patients with chronic lymphocytic leukemia were infusion reactions and low white blood cells. Before starting treatment with RITUXAN it is important to talk to your doctor about your medical history.
Tell your doctor about any side effect that bothers you or that does not go away. These are not all of the possible side effects with RITUXAN. For more information, ask your doctor.
Please see full Prescribing Information, including the Medication Guide.
Rituxan® and its logo are trademarks of Biogen Idec, Inc.
The Access Solutions logo and the Access Solutions Treatment made possible logo are trademarks of Genentech USA, Inc.
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