GAZYVA Access Solutions is a resource for people who take a Genentech medicine. We connect you to the medicine you have been prescribed.

Genentech is the company that makes GAZYVA. We believe every person should get the Genentech medicine their doctor prescribed and we offer programs to help make this happen.

There may be options to help you get the Genentech medicine your doctor has prescribed. GAZYVA Access Solutions can refer you to financial assistance options.

You might not be able to get your Genentech medicine right away. First, your doctor’s office or specialty pharmacy will have to check to make sure your health insurance plan covers your medicine. This is called a “benefits investigation.” They also might have to send some more information before your plan covers your medicine. This is called a “prior authorization.”

1. You fill out the Patient Consent Form.
2. Your doctor fills out the Prescriber Service Form. You do not have to fill out anything on this form.
3. Your doctor sends both of these forms to GAZYVA Access Solutions.

There are 3 ways to send us the Patient Consent Form:

• Complete it online at Genentech-Access.com/PatientConsent
• Text a picture of the completed form to (650) 877-1111
• Fill out a paper copy and fax or mail it to us (or give it to your doctor to do so)

The Patient Consent Form gives us permission to discuss your health information with others, such as your doctor and your health insurance plan, so we can perform our services. We can’t work with you without a signed Patient Consent Form.

You do not need to do anything else, but your doctor does. He or she needs to submit the Prescriber Service Form. This form tells us your doctor wants to treat you with GAZYVA. Make sure your doctor has sent us the Prescriber Service Form so you get help from us.

You do not need to fill out anything on the Prescriber Service Form.

If your health insurance plan will not cover your Genentech medicine, you and your doctor’s office can file an appeal. Contact your doctor to ask if you should file an appeal.

We have resources to help you and your doctor file an appeal.

GAZYVA Access Solutions cannot complete or submit an appeal for you.

We have resources to help you and your doctor file an appeal. You or your doctor’s office has to file the appeal directly with your health insurance plan.

GAZYVA Access Solutions cannot complete or submit an appeal for you.

This depends on your health insurance plan. You should ask your plan directly about its process. Sometimes the appeals process is quick. However, it can take several months if you have to appeal several times.

GAZYVA Access Solutions cannot complete or submit an appeal for you.

If your insurance changes while you’re taking your Genentech medicine, call us. We can help you understand your new coverage.

The Genentech Patient Foundation gives free Genentech medicine to people who don’t have health insurance coverage or who have financial concerns and meet certain eligibility criteria.