Practice Forms and Documents

Find the enrollment forms you'll need to help patients access ENSPRYNG 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.

Quick Links

ENSPRYNG Access Solutions Enrollment Forms

ENSPRYNG Access Solutions can help your patients better understand their coverage, find financial assistance options, learn how to get ENSPRYNG, understand which specialty pharmacy their health insurance plan requires, reverify coverage if needed and enroll in additional support options in the event of a coverage delay.

ENSPRYNG Start Form & Patient Consent Form

To enroll your patient in ENSPRYNG Access Solutions you must complete the prescriber section of the ENSPRYNG Start Form and your patient must provide their written consent.

Your patient's consent authorizes ENSPRYNG Access Solutions to discuss their health information with you and their health insurance provider. Your patient can provide their written permission by completing either the patient consent section of the ENSPRYNG Start Form or the optional Patient Consent Form.

Both the prescriber and patient consent sections are required. We must have both sections completed before we can help you.

Genentech Patient Foundation Enrollment Forms

The Genentech Patient Foundation provides free ENSPRYNG 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. Learn more about the Genentech Patient Foundation and other resources programs.

Prescriber Foundation Form

Includes patient, insurance and prescription information. Page two must be completed and submitted by the prescriber.

Patient Consent Form

This form is signed and dated by your patient, giving written permission for ENSPRYNG Access Solutions to discuss their health information with you and the patient's health insurance plan.

Tips for Composing Letters of Medical Necessity and Appeal

Letter of Medical Necessity

This guide provides tips to help you draft a letter of medical necessity. A sample letter is also included for your reference.

Appeal Letter

This guide provides tips to help you draft an appeal letter. A sample letter is also included for your reference.

Appeals

Use the links below to find additional information to enclose in your letter of medical necessity or appeal letter:

Important Safety Information & Indication

Indication

ENSPRYNG is indicated for the treatment of neuromyelitis optica spectrum disorder (NMOSD) in adult patients who are anti-aquaporin-4 (AQP4) antibody positive.

Contraindications

ENSPRYNG is contraindicated in patients with a known hypersensitivity to satralizumab or any of the inactive ingredients, an active hepatitis B infection, or active or untreated latent tuberculosis.

Warnings and Precautions

Infections
An increased risk of infections, including serious and potentially fatal infections, has been observed in patients treated with IL-6 receptor antagonists, including ENSPRYNG. The most common infections reported in a randomized clinical trial of patients treated with ENSPRYNG who were not on other chronic immunosuppressant therapies, and that occurred more often than in patients receiving placebo, were nasopharyngitis (12%) and cellulitis (10%). The most common infections in patients who were on an additional concurrent immunosuppressant, and that occurred more often than in patients receiving placebo, were nasopharyngitis (31%), upper respiratory infection (19%), and pharyngitis (12%). Delay ENSPRYNG administration in patients with an active infection, including localized infections, until the infection is resolved.

Hepatitis B Virus (HBV) Reactivation
Risk of HBV reactivation has been observed with other immunosuppressant therapies. Patients with chronic HBV infection were excluded from clinical trials. Perform HBV screening in all patients before initiation of treatment with ENSPRYNG. Do not administer ENSPRYNG to patients with active hepatitis. For patients who are chronic carriers of HBV [HBsAg+] or are negative for HBsAg and positive for HB core antibody [HBcAb+], consult liver disease experts before starting and during treatment with ENSPRYNG.

Tuberculosis
Tuberculosis has occurred in patients treated with other IL-6 receptor antagonists. Patients should be evaluated for tuberculosis risk factors and tested for latent infection prior to initiating ENSPRYNG. Consider anti-tuberculosis therapy prior to initiation of ENSPRYNG in patients with a history of latent or active tuberculosis in whom an adequate course of treatment cannot be confirmed, and for patients with a negative test for latent tuberculosis but having risk factors for tuberculosis infection. Consult infectious disease experts regarding whether initiating anti-tuberculosis therapy is appropriate before starting treatment. Patients should be monitored for the development of signs and symptoms of tuberculosis with ENSPRYNG, even if initial tuberculosis testing is negative.

Vaccinations
Live or live-attenuated vaccines should not be given concurrently with ENSPRYNG because clinical safety has not been established. Administer all immunizations according to immunization guidelines at least 4 weeks prior to initiation of ENSPRYNG for live or live-attenuated vaccines and, whenever possible, at least 2 weeks prior to initiation of ENSPRYNG for non-live vaccines.

Elevated Liver Enzymes
Mild and moderate elevations of liver enzymes have been observed in patients treated with ENSPRYNG at a higher incidence than in patients receiving placebo. ALT and AST levels should be monitored every 4 weeks for the first 3 months of treatment, followed by every 3 months for one year, and thereafter, as clinically indicated.

Decreased Neutrophil Counts
Decreases in neutrophil counts were observed in patients treated with ENSPRYNG at a higher incidence than placebo. Neutrophil counts should be monitored 4 to 8 weeks after initiation of therapy, and thereafter at regular clinically determined intervals.

Hypersensitivity Reactions
Hypersensitivity reactions, including rash, urticaria, and fatal anaphylaxis, have occurred with other IL-6 receptor antagonists.

Use in Specific Populations

Pregnancy

Pregnancy Exposure Registry

There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to ENSPRYNG during pregnancy. Healthcare providers are encouraged to register patients and pregnant women are encouraged to register themselves by calling 1-833-277-9338.

There are no adequate data on the developmental risk associated with the use of ENSPRYNG in pregnant women. In an animal reproduction study, no adverse effects on maternal animals or fetal development were observed in pregnant monkeys and their offspring, with administration of ENSPRYNG at doses up to 50 mg/kg/week. In the U.S. general population, the estimated background risk of major birth defect and miscarriage in clinically recognized pregnancies is 2 – 4% and 15 – 20%, respectively. The estimated background risk of major birth defects and miscarriage for the indicated population is unknown.


Lactation
No information is available on the presence of ENSPRYNG in human milk, the effects of ENSPRYNG on the breastfed infant, or the effects of ENSPRYNG on milk production. ENSPRYNG was excreted in the milk of lactating monkeys administered ENSPRYNG throughout pregnancy. Human IgG is excreted in human milk and the potential for absorption in the infant is unknown. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for ENSPRYNG and any potential adverse effects on the breastfed infant from ENSPRYNG or from the underlying maternal condition.

Pediatric Use
Safety and effectiveness in pediatric patients have not been established.

Geriatric Use
Clinical studies of ENSPRYNG did not include sufficient numbers of patients aged 65 years and older to determine whether they respond differently from younger patients. However, population pharmacokinetic analyses in patients with NMOSD did not show that age affected the pharmacokinetics of ENSPRYNG. In general, caution should be used when dosing the elderly, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant diseases or other drug therapy.

Most Common Adverse Reactions

The most common adverse reactions (≥15% in either trial) were nasopharyngitis (31%), headache (27%), upper respiratory tract infection (19%), rash (17%), arthralgia (17%), extremity pain (15%), gastritis (15%), fatigue (15%), and nausea (15%).

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 safety information, please see the full Prescribing Information and Medication Guide.

    • ENSPRYNG [prescribing information]. South San Francisco, CA: Genentech, Inc. 2022.

      ENSPRYNG [prescribing information]. South San Francisco, CA: Genentech, Inc. 2022.

    • Heo Y-A. Satralizumab: first approval. Drugs. 2020;80(14):1477-1482. https://doi.org/10.1007/s40265-020-01380-2

      Heo Y-A. Satralizumab: first approval. Drugs. 2020;80(14):1477-1482. https://doi.org/10.1007/s40265-020-01380-2

    • Traboulsee A, Greenberg BM, Bennett JL, et al. Safety and efficacy of satralizumab monotherapy in neuromyelitis optica spectrum disorder: a randomised, double-blind, multicentre, placebo-controlled phase 3 trial. Lancet Neurol. 2020;19(5):402-412. doi:10.1016/S1474-4422(20)30078-8

      Traboulsee A, Greenberg BM, Bennett JL, et al. Safety and efficacy of satralizumab monotherapy in neuromyelitis optica spectrum disorder: a randomised, double-blind, multicentre, placebo-controlled phase 3 trial. Lancet Neurol. 2020;19(5):402-412. doi:10.1016/S1474-4422(20)30078-8

    • Kawachi I, Lassmann H. J Neurol Neurosurg Psychiatry. 2017;88:137–145. doi:10.1136/jnnp-2016-313300

      Kawachi I, Lassmann H. J Neurol Neurosurg Psychiatry. 2017;88:137–145. doi:10.1136/jnnp-2016-313300

    • Jarius S, Wildemann D, Paul F. Neuromyelitis optica: clinical features, immunopathogenesis and treatment. Clinical and Experimental Immunology. 2014;176:149–164. doi:10.1111/cei.12271

      Jarius S, Wildemann D, Paul F. Neuromyelitis optica: clinical features, immunopathogenesis and treatment. Clinical and Experimental Immunology. 2014;176:149–164. doi:10.1111/cei.12271

    • Yamamura T, Kleiter I, Fujihara K, et al. Trial of satralizumab in neuromyelitis optica spectrum disorder. N Engl J Med. 2019;381(22):2114-2124.

      Yamamura T, Kleiter I, Fujihara K, et al. Trial of satralizumab in neuromyelitis optica spectrum disorder. N Engl J Med. 2019;381(22):2114-2124.

    • Huda S, Whittam D, Bhojak M, et al. Neuromyelitis optica spectrum disorders. Clinical Medicine. 2019; 19(2):169–176.

      Huda S, Whittam D, Bhojak M, et al. Neuromyelitis optica spectrum disorders. Clinical Medicine. 2019; 19(2):169–176.

    • Chihara N, Aranami T, Sato W, et al. Interleukin 6 signaling promotes anti-aquaporin 4 autoantibody production from plasmablasts in neuromyelitis optica. Proc Natl Acad Sci USA. 2011;108(9):3701-3706.

      Chihara N, Aranami T, Sato W, et al. Interleukin 6 signaling promotes anti-aquaporin 4 autoantibody production from plasmablasts in neuromyelitis optica. Proc Natl Acad Sci USA. 2011;108(9):3701-3706.

    • Knapp RK, Hardtstock F, Wilke T, et al. Evaluating the economic burden of relapses in neuromyelitis optica spectrum disorder: a real-world analysis using German claims data. Neurol Ther. 2022;11:247-263. https://doi.org/10.1007/s40120-021-00311-x

      Knapp RK, Hardtstock F, Wilke T, et al. Evaluating the economic burden of relapses in neuromyelitis optica spectrum disorder: a real-world analysis using German claims data. Neurol Ther. 2022;11:247-263. https://doi.org/10.1007/s40120-021-00311-x

    • Contentti EC, Rojas JI, Cristiano E, et al. Latin American consensus recommendations for management and treatment of neuromyelitis optica spectrum disorders in clinical practice. Mult Scler Relat Disord. 2020;45:102428. doi: 10.1016/j.msard.2020.102428

      Contentti EC, Rojas JI, Cristiano E, et al. Latin American consensus recommendations for management and treatment of neuromyelitis optica spectrum disorders in clinical practice. Mult Scler Relat Disord. 2020;45:102428. doi: 10.1016/j.msard.2020.102428

    • Takeshita Y, Obermeier B, Cotleur AC, et al. Effects of neuromyelitis optica-IgG at the blood-brain barrier in vitro. Neurol Neuroimmunol Neuroinflamm. 2016;4(1):e311. doi:10.1212/NXI.0000000000000311

      Takeshita Y, Obermeier B, Cotleur AC, et al. Effects of neuromyelitis optica-IgG at the blood-brain barrier in vitro. Neurol Neuroimmunol Neuroinflamm. 2016;4(1):e311. doi:10.1212/NXI.0000000000000311

    • Obermeier B, Daneman R, Ransohoff RM. Development, maintenance and disruption of the blood-brain barrier. Nat Med. 2013;19(12):1584-1596. doi:10.1038/nm.3407

      Obermeier B, Daneman R, Ransohoff RM. Development, maintenance and disruption of the blood-brain barrier. Nat Med. 2013;19(12):1584-1596. doi:10.1038/nm.3407

    • Chugai Pharmaceutical Co, LTD. SMART-Ig. Accessed February 17, 2022. https://www.chugai-pharm.co.jp/english/ir/rd/technologies/files/eChugaiProprietaryTechnologies.pdf

      Chugai Pharmaceutical Co, LTD. SMART-Ig. Accessed February 17, 2022. https://www.chugai-pharm.co.jp/english/ir/rd/technologies/files/eChugaiProprietaryTechnologies.pdf

    • Igawa T, Tsunoda H, Kuramochi T, Sampei Z, Ishii S, Hattori K. Engineering the variable region of therapeutic IgG antibodies. MAbs. 2011;3(3):243-252.

      Igawa T, Tsunoda H, Kuramochi T, Sampei Z, Ishii S, Hattori K. Engineering the variable region of therapeutic IgG antibodies. MAbs. 2011;3(3):243-252.

    • Data on file. Genentech, Inc. South San Francisco, CA.

      Data on file. Genentech, Inc. South San Francisco, CA.

    • Barros PO, Cassano T, Hygino J, et al. Prediction of disease severity in neuromyelitis optica by the levels of interleukin (IL)-6 produced during remission phase. Clin Exp Immunol. 2016;183:480-489.

      Barros PO, Cassano T, Hygino J, et al. Prediction of disease severity in neuromyelitis optica by the levels of interleukin (IL)-6 produced during remission phase. Clin Exp Immunol. 2016;183:480-489.