Genentech Access Solutions Committed to Helping You Get Your Genentech Medicine

Tami, Genentech Access Solutions patient

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A commercial insurance plan (such as one you get through your employer or through a Health Insurance Marketplace like HealthCare.gov)

A public insurance plan (such as Medicare or Medicaid)

No insurance

What Is Genentech Access Solutions?

Genentech Access Solutions helps people after they have been prescribed Genentech medicines.

There may be assistance for people taking Genentech medicines who have:

You might get a phone call from Genentech Access Solutions or your specialty pharmacy.

Make sure you return all phone calls so we can help you get your medicine.

What Can I Expect?

Genentech Access Solutions can:

Help you understand your health insurance coverage by finding out:

• If your health insurance covers your Genentech medicine

• How much your co-pay will be for your medicine

Refer you to patient assistance options:

• Genentech co-pay card programs

• Independent co-pay assistance foundations

• The Genentech® Access to Care Foundation (GATCF)

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‡ If you have health insurance, you must have already tried other types of patient assistance to qualify for free medicine from GATCF. This includes Genentech co-pay cards and support from independent co-pay assistance foundations. You must also meet financial criteria. If you do not have health insurance, you must meet different financial criteria.

What Is Patient Assistance?

Even if you have health insurance, you might feel concerned about the cost of your treatment.

We can refer you to patient assistance options to help you afford the Genentech medicine you need.

COMMERCIALLY INSURED PATIENTS

PUBLICLY INSURED PATIENTS

UNINSUREDPATIENTS

GENENTECHBRAND-SPECIFICCO-PAY CARDS*

REFERRALS TO BRAND-SPECIFIC PATIENT SUPPORT

INDEPENDENT CO-PAY ASSISTANCE FOUNDATIONS†

GENENTECH® ACCESS TO CARE FOUNDATION (GATCF)‡

GENENTECH ACCESS SOLUTIONS REFERRALS TO PATIENT ASSISTANCE

* To qualify for a Genentech brand-specific co-pay card program, you must have commercial insurance, such as a plan you get through your employer. If you have Medicare, Medicaid or other public insurance, you are not eligible for this program. You must also meet other criteria.

† Independent co-pay assistance foundations have their own rules for eligibility. We cannot guarantee a foundation will help you. We can only refer you to a foundation that supports your disease state. We do not endorse or show financial preference for any particular foundation. The foundations we refer you to are not the only ones that might be able to help you.

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Where Can I Learn More?

Visit Genentech-Access.com/patients to learn how Genentech Access Solutions may be able to help you.

At Genentech-Access.com/patients, you can:

Learn about patient assistance options

Find out which option may be right for you

Download the form you need to enroll

Our Patient Assistance Tool helps you find out which of our patient assistance options may be right for you. Answer a few questions to learn which options you might qualify for.

You can also view this website in Spanish.

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What Do I Need to Sign Up?

There are 2 forms you and your doctor need to complete to enroll in Genentech Access Solutions:

The PAN is a form you must sign and date to enroll. This form lets us discuss your health information with your doctor and your health insurance plan.

The SMN is a form filled out by your doctor. This form tells us about your insurance information and how your doctor has prescribed a Genentech medicine.

You do not need to fill out anything on the SMN form.

PAN=Patient Authorization and Notice of Request for Transmission of Health Information to Genentech Access Solutions and Genentech® Access to Care Foundation.

SMN=Statement of Medical Necessity.

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Where Do I Find the PAN Form?

You can find the PAN form at Genentech-Access.com/PAN

There are 2 ways to fill out the PAN form:

You can fill out the form online.

You can download and print it to fill out a paper copy.

How Do I Sign Up?

You fill out the PAN form.

Your doctor fills out the SMN form. You do not have to fill out anything on this form.

Your doctor sends both of these forms to Genentech Access Solutions.

Information About Your Medicine

Use this space to write information about your medicine. Keep these notes on hand. They might help you answer questions if Genentech Access Solutions or your specialty pharmacy calls you.

Name of medicine: ____________________

______________________________________

Doctor’s name: ________________________

______________________________________

To learn more about your patient assistance options

Call (866) 422-2377

Visit Genentech-Access.com/patients

©2018 Genentech USA, Inc. So. San Francisco, CA All rights reserved. ACS/082614/0008(3) 1/18 Printed in USA

The Access Solutions logo is a registered trademark of Genentech, Inc.