ACTEMRA® (tocilizumab)
ALECENSA® (alectinib)
Avastin® (bevacizumab)
COTELLIC® (cobimetinib)
ENSPRYNG® (satralizumab-mwge)
Erivedge® (vismodegib)
Esbriet® (pirfenidone)
Evrysdi® (risdiplam)
GAVRETO® (pralsetinib)
GAZYVA® (obinutuzumab)
HEMLIBRA® (emicizumab-kxwh)
Herceptin® (trastuzumab)
Herceptin HYLECTA™ (trastuzumab and hyaluronidase-oysk)
KADCYLA® (ado-trastuzumab emtansine)
LUCENTIS® (ranibizumab injection)
LUNSUMIO™ (mosunetuzumab-axgb)
OCREVUS® (ocrelizumab)
PERJETA® (pertuzumab)
PHESGO™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
POLIVY® (polatuzumab vedotin-piiq)
Pulmozyme® (dornase alfa) Inhalation Solution
Rituxan® (rituximab) for Rheumatoid Arthritis (RA)
RITUXAN® (rituximab) for Oncology
Rituxan® (rituximab) for Granulomatosis with Polyangiitis (GPA), Microscopic Polyangiitis (MPA) or Pemphigus Vulgaris (PV)
RITUXAN HYCELA® (rituximab/hyaluronidase human)
ROZLYTREK® (entrectinib)
SUSVIMO™ (ranibizumab injection)
TECENTRIQ® (atezolizumab)
VABYSMO® (faricimab-svoa)
VENCLEXTA® (venetoclax tablets)
XELODA® (capecitabine)
XOLAIR® (omalizumab) for subcutaneous use
ZELBORAF® (vemurafenib)
Oncology
Ophthalmology
Rheumatology
Enrollment forms and other important documents can be found below. To use Quick Enroll for the Prescriber Service Form, select eSubmit.
Esbriet Access Solutions Enrollment Forms
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Prescriber Service Form
The Prescriber Service Form is filled out by the health care provider and is used to collect the patient’s health insurance and treatment information. -
Patient Consent Form
The Patient Consent Form is filled out by the patient and gives permission for Genentech to work with the health care provider and the patient’s health insurance plan. -
Formulario de Consentimiento del Paciente
El Formulario de Consentimiento del Paciente nos da permiso para analizar su información de salud con otras personas, como su médico y su plan de seguro médico, para que podamos prestar nuestros servicios.
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Complete and submit a form electronically.
Other Important Documents
Enrolling in the Genentech Patient Foundation
The Genentech Patient Foundation gives free Genentech medicine to people who don't have insurance or who have financial concerns and meet eligibility criteria. Two forms are needed to enroll in the Genentech Patient Foundation:
- Prescriber Foundation Form (to be completed by the health care provider).
- Patient Consent Form (to be completed by the patient).
For more information, visit GenentechPatientFoundation.com.
Considerations for Composing a 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. Use the links below to find additional information to enclose in your letter.
FDA approval letter (Follow this link and search by the drug name)
Considerations for Composing a Sample Appeal Letter
This guide provides tips to help you draft an appeal letter. A sample letter is also included for your reference. Use the links below to find additional information to enclose in your letter.
FDA approval letter (Follow this link and search by the drug name)
Esbriet Recertification Reminder Program Enrollment Form
Complete this form to enroll your patients in the Esbriet Recertification Reminder Program to help avoid potential gaps in their Esbriet therapy due to health insurance plan recertification requirements.
Fax Cover Letter
Use this cover sheet when faxing documents to Esbriet Access Solutions.
For assistance, call (877) GENENTECH/(877) 436-3683
6 a.m.–5 p.m. PT, Monday through Friday
Patient Assistance Tool
Find the right assistance option for your patients