Forms and Documents

Download the form you need to enroll in Genentech Access Solutions and a helpful guide to use when talking to your doctor’s office.

Start Enrollment With the Patient Consent Form

To get started, fill out the Patient Consent Form. This form replaces the Patient Authorization and Notice of Request for Transmission of Health Information to Genentech Access Solutions and Genentech® Access to Care Foundation (PAN).

You can complete this form in 1 of 3 ways:

  • Fill out and submit the form online
  • Sign a printed form, take a photo and text it to  (650) 877-1111
  • Sign a printed form and fax or mail it to us (or give it to your doctor’s office to do so)

Your doctor also has to fill out a form called the Prescriber Service Form. Once we have both these forms, we can begin working with you and your doctor’s office. You do not need to fill out anything on the Prescriber Service Form.

Treatment Cost Discussion Guide

This information packet includes:

  • Questions to consider asking someone at your doctor's office after you have been prescribed a Genentech medicine
  • Information on how to enroll in Herceptin Hylecta Access Solutions
  • A copy of the Patient Consent Form

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

Important Safety Information & Indication

What it treats

Adjuvant Breast Cancer

HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) is approved for the treatment of adults with early-stage breast cancer that is Human Epidermal growth factor Receptor 2-positive (HER2+) and has spread into the lymph nodes, or is HER2-positive and has not spread into the lymph nodes. If it has not spread into the lymph nodes, the cancer needs to be estrogen receptor/progesterone receptor (ER/PR)-negative or have one high-risk feature.* HERCEPTIN HYLECTA can be used in several different ways:

  • As part of a treatment course including the chemotherapy drugs doxorubicin, cyclophosphamide, and either paclitaxel or docetaxel. This treatment course is known as “AC→TH
  • With the chemotherapy drugs docetaxel and carboplatin. This treatment course is known as “TCH
  • Alone after treatment with multiple other therapies, including an anthracycline (doxorubicin) based therapy (a type of chemotherapy)

Patients are selected for therapy based on an FDA-approved test for trastuzumab.

*High risk is defined as ER/PR-positive with one of the following features: tumor size >2 cm, age <35 years, or tumor grade 2 or 3.

Metastatic Breast Cancer

HERCEPTIN HYLECTA has 2 approved uses in adults with metastatic breast cancer:

  • HERCEPTIN HYLECTA in combination with the chemotherapy drug paclitaxel is approved for the first line treatment of Human Epidermal growth factor Receptor 2-positive (HER2+) metastatic breast cancer
  • HERCEPTIN HYLECTA alone is approved for the treatment of HER2-positive breast cancer in patients who have received one or more chemotherapy courses for metastatic disease

Patients are selected for therapy based on an FDA-approved test for trastuzumab.

Important Patient Safety Information

Possible Serious Side Effects With HERCEPTIN HYLECTA

Not all people have serious side effects, but side effects with HERCEPTIN HYLECTA therapy are common.

Although some people may have a life-threatening side effect, most do not.

Your doctor will stop treatment if any serious side effects occur.

HERCEPTIN HYLECTA is not for everyone. Be sure to contact your doctor if you are experiencing any of the following:

HEART PROBLEMS

These include heart problems—such as congestive heart failure or reduced heart function—with or without symptoms. The risk for and seriousness of these heart problems were highest in people who received both HERCEPTIN HYLECTA and a certain type of chemotherapy (anthracycline). In a study of adjuvant (early) breast cancer, one patient died of significantly weakened heart muscle. Your doctor will check for signs of heart problems before, during, and after treatment with HERCEPTIN HYLECTA.

Contact a health care professional immediately for any of the following: new onset or worsening shortness of breath, cough, swelling of the ankles/legs, swelling of the face, palpitations, weight gain of more than 5 pounds in 24 hours, dizziness or loss of consciousness.

SEVERE LUNG PROBLEMS including:

  • Severe shortness of breath
  • Scarring of the lungs
  • Fluid in or around the lungs
  • Weakening of the valve between the heart and the lungs
  • Not enough oxygen in the body
  • Swelling of the lungs

Your doctor may check for signs of severe lung problems when he or she examines you.

These signs usually happen within 24 hours after receiving HERCEPTIN HYLECTA.

BE SURE TO CONTACT YOUR DOCTOR IF YOU:

ARE A WOMAN WHO COULD BECOME PREGNANT, OR MAY BE PREGNANT

HERCEPTIN HYLECTA may result in the death of an unborn baby or birth defects. Contraception should be used while receiving HERCEPTIN HYLECTA and for 7 months after your last dose of HERCEPTIN HYLECTA. If you are or become pregnant while receiving HERCEPTIN HYLECTA or within 7 months after your last dose of HERCEPTIN HYLECTA, you are encouraged to report HERCEPTIN HYLECTA exposure to Genentech at 1-888-835-2555.

Have LOW WHITE BLOOD CELL COUNTS

Low white blood cell counts can be life threatening. Low white blood cell counts were seen more often in patients receiving intravenous trastuzumab plus chemotherapy than in patients receiving chemotherapy alone.

Your doctor may check for signs of low white blood cell counts when he or she examines you.

Experience HYPERSENSITIVITY AND ADMINISTRATION-RELATED REACTIONS, which have been reported with HERCEPTIN HYLECTA. Serious and fatal reactions have been reported after treatment with intravenous trastuzumab products. Your doctor will monitor you for signs of these reactions.  Contact your healthcare provider immediately if you experience any symptoms of hypersensitivity and administration-related reactions, including dizziness, nausea, chills, fever, vomiting, diarrhea, hives, swelling under the skin, breathing problems, or chest pain.

SIDE EFFECTS SEEN MOST OFTEN

The most common side effects seen in treatment of adjuvant breast cancer with HERCEPTIN HYLECTA were tiredness, joint pain, diarrhea, injection site reaction, upper respiratory tract infection, rash, muscle pain, nausea, headache, swelling, flushing, fever, cough, and pain in extremity.

The most common side effects seen in treatment of metastatic breast cancer (based on intravenous trastuzumab) are fever, chills, headache, infection, congestive heart failure, insomnia, cough, and rash.

You should contact your doctor immediately if you have any of the side effects listed above.

You are encouraged to report side effects to Genentech and the FDA. You may report side effects to the FDA at 1-800-FDA-1088 or http://www.fda.gov/medwatch.

You may also report side effects to Genentech at 1-888-835-2555.

Please see the HERCEPTIN HYLECTA full Prescribing Information for additional Important Safety Information, including most serious side effects.