ACTEMRA® (tocilizumab)
ALECENSA® (alectinib)
Avastin® (bevacizumab)
COLUMVI® (glofitamab-gxbm)
COTELLIC® (cobimetinib)
ENSPRYNG® (satralizumab-mwge)
Erivedge® (vismodegib)
Evrysdi® (risdiplam)
GAZYVA® (obinutuzumab)
HEMLIBRA® (emicizumab-kxwh)
Herceptin® (trastuzumab)
Herceptin HYLECTA™ (trastuzumab and hyaluronidase-oysk)
Itovebi™ (inavolisib)
KADCYLA® (ado-trastuzumab emtansine)
LUCENTIS® (ranibizumab injection)
LUNSUMIO® (mosunetuzumab-axgb)
OCREVUS® (ocrelizumab) and OCREVUS ZUNOVO® (ocrelizumab & hyaluronidase-ocsq)
PERJETA® (pertuzumab)
PHESGO® (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
PiaSky™ (crovalimab-akkz)
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)
TECENTRIQ HYBREZA™ (atezolizumab and hyaluronidase-tqjs)
VABYSMO® (faricimab-svoa)
VENCLEXTA® (venetoclax tablets)
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.
HEMLIBRA 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. -
Spanish Patient Consent Form (Formulario de Consentimiento del Paciente)
A version of the Patient Consent Form for your Spanish-speaking patients.
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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 health insurance coverage 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)
Access Process Tips for HEMLIBRA
Use this worksheet to help you determine which information to include with the prior authorization (PA) and/or appeals submission.
Fax Cover Letter
Use this cover sheet when faxing documents to HEMLIBRA Access Solutions.
