Statement of Medical Necessity (SMN) Form
The SMN is needed to refer your patient to Pulmozyme 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 Pulmozyme Access Solutions. The physician must sign and date the SMN.
Pulmozyme (dornase alfa) Inhalation Solution Important Information
Indication and Usage
Daily administration of Pulmozyme in conjunction with standard therapies is indicated in the management of cystic fibrosis (CF) patients to improve pulmonary function. In patients with an FVC 
40% of predicted, daily administration of Pulmozyme has also been shown to reduce the risk of respiratory tract infections requiring parenteral antibiotics.
Safety and efficacy of daily administration have not been demonstrated in patients for longer than 12 months.
Important Safety Information
Pulmozyme should not be used in patients who are allergic to any of its ingredients. Pulmozyme should be used in conjunction with standard therapies for CF. When starting Pulmozyme therapy, patients may experience change in or loss of voice, discomfort in the throat, chest pain, red watery eyes, rash, dizziness, fever, or runny nose. These side effects are usually mild and short-lived.
For further information, please see the Pulmozyme full Prescribing Information. If you have questions, please discuss them with your CF health care team.
Pulmozyme® is a registered trademark and the Access Solutions logo and the Access Solutions Treatment made possible logo are trademarks of Genentech USA, Inc.
