How It Works

Applying for the Rituxan Immunology and ACTEMRA Co-pay Card Program

Provide each new patient with a Rituxan Immunology and ACTEMRA Co-pay Card Program application brochure for Rituxan or ACTEMRA or ask them to visit RACopay.com to request a brochure.

Ready to apply on behalf of your patients?

Important: Before beginning the application process, the patient or patient's guardian should have the following on hand:

Patient's:

- Co-pay card (if they have one already)
- Address, phone number, email address
- Birth date
- Last 4 digits of Social Security number
- Insurance card

Physician's name, address and phone number

Using the Card

For Rituxan and ACTEMRA Intravenous (IV) Patients Under the Medical Benefit

For a physician's office or hospital

Practice completes a one-time registration by calling (855) RA-COPAY (855-722-6729). (Please note: This registration is for the practice only). At the time of enrollment, we also can:
- Give you a password for the Tool Center so you can manage all co-pay cards associated with your practice online
- Link multiple providers in your practice to your account
Practice gives the patient an application brochure for Rituxan or ACTEMRA or asks them to visit RACopay.com to request a brochure.
Patient, caregiver or practice applies on behalf of the patient.
Practice administers infusion.
Practice faxes a copy of the patient's detailed EOB to (800) 334-3030. Co-pay amount minus the patient out-of-pocket responsibility is loaded onto the card after verification.

For providers^† without a credit card terminal

Before treatment

Provider confirms patient's enrollment in the program online or by phone at (855) RA-COPAY (855-722-6729).
Patient downloads the Check Request Form from the Downloadable Forms section.

After treatment

Patient completes the Check Request Form and sends it to Genentech, along with copies of the detailed EOB and receipt illustrating payment, via:
- Fax: (800) 334-3030
- Mail to:
  Rituxan Immunology and ACTEMRA Co-pay Card Program
  100 Passaic Ave, Suite 245
  Fairfield, NJ 07004

A check is issued to the recipient indicated on the Check Request Form:
- Checks are issued with the patient name, account number and program name in the reference line
- Check reimbursements take 7 to 10 business days, provided all documentation received is complete

For ACTEMRA Subcutaneous (SC) Patients Under the Pharmacy Benefit

For a specialty pharmacy (SP)

SP completes a one-time registration by calling (855) RA-COPAY (855-722-6729). (Please note: This registration is for the SP only). During this call, we also can provide a password for the Tool Center so they can manage all co-pay cards associated with their SP online.
Practice gives the patient an application brochure for Rituxan or ACTEMRA or asks them to visit RACopay.com to request a brochure.
Patient or practice applies on behalf of the patient.
Practice sends prescription to SP and informs the patient the ACTEMRA SC is being shipped by SP.
Patient gives the SP the RxBIN and Member ID from the card when SP calls to collect co-pay.
SP collects the patient's OOP costs using the RxBIN and Member ID.

For a community/retail pharmacy

Practice completes a one-time registration by calling (855) RA-COPAY (855-722-6729). (Please note: This registration is for the practice only). During this call, we also can:
- Give you a password for the Tool Center so you can manage all co-pay cards associated with your practice online
- Link multiple providers in your practice to your account
Practice gives patient an application brochure for Rituxan or ACTEMRA or asks them to visit RACopay.com to request a brochure.
Patient or practice applies on behalf of the patient.
Practice sends prescription to selected community/retail pharmacy and informs the patient the ACTEMRA SC has been ordered at a community/retail pharmacy.
Patient brings the card to the community/retail pharmacy to pick up the ACTEMRA SC.
Community/retail pharmacy collects the patient's OOP costs by swiping the card or using the RxBIN and Member ID.

For SPs or community/retail pharmacies without a credit card terminal

SP confirms patient's enrollment in the program online or by phone at (855) RA-COPAY (855-722-6729).
Patient completes the Check Request Form found in the Downloadable Forms section and sends it to Genentech, along with copies of the detailed EOB and receipt illustrating payment, via:
- Fax: (800) 334-3030
- Mail to:
  Rituxan Immunology and ACTEMRA Co-pay Card Program
  100 Passaic Ave, Suite 245
  Fairfield, NJ 07004
A check is issued to the recipient indicated on the Check Request Form:
- Checks are issued with the patient name, account number and program name in the reference line
- Check reimbursements take 7 to 10 business days, provided all documentation received is complete

If you have questions, please call the help desk at (855) RA-COPAY (855-722-6729).

^†Providers can include physicians, infusion centers, hospitals or SPs.

Indication and Important Safety Information

Rituxan Indications

Rituxan^® (rituximab), in combination with methotrexate, is indicated for the treatment of adult patients with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response to one or more TNF antagonist therapies
Rituxan^® (rituximab), in combination with glucocorticoids, is indicated for the treatment of adult patients with Granulomatosis with Polyangiitis (GPA) (Wegener's Granulomatosis) and Microscopic Polyangiitis (MPA)
Rituxan^® (rituximab), is indicated for the treatment of adult patients with moderate to severe pemphigus vulgaris

BOXED WARNINGS and Additional Important Safety Information

BOXED WARNINGS

Infusion-Related Reactions: Rituxan administration can result in serious, including fatal infusion-related reactions. Deaths within 24 hours of Rituxan infusion have occurred. Approximately 80% of fatal infusion reactions occurred in association with the first infusion. Monitor patients closely. Discontinue Rituxan infusion for severe reactions and provide medical treatment for Grade 3 or 4 infusion-related reactions.

Severe Mucocutaneous Reactions: Severe, including fatal, mucocutaneous reactions can occur in patients receiving Rituxan.

Hepatitis B Virus (HBV) Reactivation: HBV reactivation can occur in patients treated with Rituxan, in some cases resulting in fulminant hepatitis, hepatic failure, and death. Screen all patients for HBV infection before treatment initiation, and monitor patients during and after treatment with Rituxan. Discontinue Rituxan and concomitant medications in the event of HBV reactivation.

Progressive Multifocal Leukoencephalopathy (PML), including fatal PML, can occur in patients receiving Rituxan.

Warnings and Precautions

Rituxan administration can also result in additional serious, including fatal, adverse reactions including:

Tumor lysis syndrome (TLS): Administer aggressive intravenous hydration, anti-hyperuricemic agents, monitor renal function
Infections: Withhold Rituxan and institute appropriate anti-infective therapy. Rituxan is not recommended for use in patients with severe, active infections
Cardiovascular adverse reactions: Discontinue infusions in case of serious or life-threatening events
Renal toxicity: Discontinue in patients with rising serum creatinine or oliguria
Bowel obstruction and perforation: Consider and evaluate for abdominal pain, vomiting, or related symptoms
Immunizations: Live virus vaccinations prior to or during Rituxan treatment are not recommended
Embryo-Fetal toxicity: Can cause neonatal harm. Advise of potential risk to neonates and use of effective contraception
Patients with RA should be closely observed for signs of infection if biologic agents and/or DMARDs other than methotrexate are used concomitantly
The use of Rituxan in patients with RA who have not had prior inadequate response to one or more TNF antagonists is not recommended
Use of concomitant immunosuppressants other than corticosteroids has not been studied in GPA, MPA, or PV patients exhibiting peripheral B-cell depletion following treatment with Rituxan

Most Common Adverse Reactions

Rheumatoid Arthritis (RA)
Most common adverse reactions (≥10%) were upper respiratory tract infection, nasopharyngitis, urinary tract infection, and bronchitis. Other important adverse reactions include infusion-related reactions, serious infections, and cardiovascular events.

Granulomatosis With Polyangiitis (GPA) (Wegener's Granulomatosis) and Microscopic Polyangiitis (MPA)
Most common adverse reactions (≥15%) were infections, nausea, diarrhea, headache, muscle spasms, anemia, and peripheral edema. Other important adverse reactions include infusion-related reactions.

Pemphigus Vulgaris (PV)
Most common adverse reactions (≥15%) were infusion-related reactions and depression. Other important adverse reactions include infections.

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.

For additional Important Safety Information, please see the Rituxan full Prescribing Information, including BOXED WARNINGS.

ACTEMRA INDICATIONS

ACTEMRA is indicated for the treatment of adult patients with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response to one or more Disease-Modifying Anti-Rheumatic Drugs (DMARDs).

ACTEMRA is indicated for the treatment of giant cell arteritis (GCA) in adult patients.

ACTEMRA is indicated for the treatment of active polyarticular juvenile idiopathic arthritis in patients 2 years of age and older.

ACTEMRA is indicated for the treatment of active systemic juvenile idiopathic arthritis in patients 2 years of age and older.

BOXED WARNING and Additional Important Safety Information

RISK OF SERIOUS INFECTIONS:

Patients treated with ACTEMRA are at increased risk for developing serious infections that may lead to hospitalization or death, including tuberculosis (TB), bacterial, invasive fungal, viral, or other opportunistic infections. If a serious infection develops, interrupt ACTEMRA until the infection is controlled.

Reported infections include:

Active tuberculosis, which may present with pulmonary or extrapulmonary disease. Patients should be tested for latent tuberculosis before ACTEMRA use and during therapy. Treatment for latent infection should be initiated prior to ACTEMRA use.

Invasive fungal infections, including candidiasis, aspergillosis, and pneumocystis. Patients with invasive fungal infections may present with disseminated, rather than localized, disease.

Bacterial, viral and other infections due to opportunistic pathogens.

The risks and benefits of treatment with ACTEMRA should be carefully considered prior to initiating therapy in patients with chronic or recurrent infection.

Patients should be closely monitored for the development of signs and symptoms of infection during and after treatment with ACTEMRA, including the possible development of tuberculosis in patients who tested negative for latent tuberculosis infection prior to initiating therapy.

ACTEMRA is contraindicated in patients with known hypersensitivity to ACTEMRA.

Other serious or potentially life-threatening adverse reactions that have been reported in clinical trials with ACTEMRA include gastrointestinal perforations. Use ACTEMRA with caution in patients who may be at risk for GI perforations.

Laboratory monitoring is recommended due to potential consequences of treatment-related laboratory abnormalities in neutrophils, platelets, lipids, and liver function tests.

Hypersensitivity reactions, including anaphylaxis and death, have occurred.

If anaphylaxis or other hypersensitivity reaction occurs, stop administration of ACTEMRA immediately and discontinue ACTEMRA permanently.

Avoid use of live vaccines concurrently with ACTEMRA, as clinical safety has not been established.

Other potential risks of ACTEMRA include demyelinating disorders and malignancies.

Treatment with ACTEMRA is not recommended in patients with active hepatic disease or hepatic impairment.

Most common adverse reactions (≥5%) include upper respiratory tract infections, nasopharyngitis, headache, hypertension, increased ALT, injection site reactions (SC only).

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.

Please see accompanying full Prescribing Information, including BOXED WARNING, for additional important safety information.