Find the enrollment forms you'll need to help patients access GAZYVA after it's been prescribed, including for coverage, reimbursement and financial assistance services. There are also tips for composing a letter of medical necessity and appeal letter.
To learn more about the resources available to help your practice, including information on benefits investigations and prior authorizations, go to Helpful Resources for Your Practice.
GAZYVA Access Solutions can help your patients better understand their coverage, find financial assistance options, learn how to get GAZYVA and know which specialty pharmacy their health insurance plan requires.
This form is used to collect the patient’s health insurance and treatment information for enrollment in GAZYVA Access Solutions.
This form is signed and dated by your patient, giving written permission for Genentech Access Solutions to discuss their health information with you and the patient's health insurance plan.
A version of the Patient Consent Form for your Spanish-speaking patients.
The Genentech Patient Foundation provides free GAZYVA to people who don’t have insurance coverage or who have financial concerns and meet eligibility criteria.
The following forms are needed for applying for assistance from the Genentech Patient Foundation. Learn more about the Genentech Patient Foundation and other resources programs.
Includes patient, insurance and prescription information. Page two must be completed and submitted by the prescriber.
This form is signed and dated by your patient, giving written permission for GAZYVA Access Solutions to discuss their health information with you and the patient's health insurance plan.
A version of the Patient Consent Form for your Spanish-speaking patients.
This guide provides tips to help you draft a letter of medical necessity. A sample letter is also included for your reference.
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 of medical necessity or appeal letter:
GAZYVA full Prescribing Information. South San Francisco, CA: Genentech, Inc.; 2021.
GAZYVA full Prescribing Information. South San Francisco, CA: Genentech, Inc.; 2021.
Mössner E, Brünker P, Moser S, et al. Increasing the efficacy of CD20 antibody therapy through the engineering of a new type II anti-CD20 antibody with enhanced direct and immune effector cell–mediated B-cell cytotoxicity. Blood. 2010;115(22):4393-4402.
Mössner E, Brünker P, Moser S, et al. Increasing the efficacy of CD20 antibody therapy through the engineering of a new type II anti-CD20 antibody with enhanced direct and immune effector cell–mediated B-cell cytotoxicity. Blood. 2010;115(22):4393-4402.
Herter S, Herting F, Mundigl O, et al. Preclinical activity of the type II CD20 antibody GA101 (obinutuzumab) compared with rituximab and ofatumumab in vitro and in xenograft models. Mol Cancer Ther. 2013;12(10):2031-2042.
Herter S, Herting F, Mundigl O, et al. Preclinical activity of the type II CD20 antibody GA101 (obinutuzumab) compared with rituximab and ofatumumab in vitro and in xenograft models. Mol Cancer Ther. 2013;12(10):2031-2042.
Klein C, Lammens A, Schäfer W, et al. Epitope interactions of monoclonal antibodies targeting CD20 and their relationship to functional properties. mAbs. 2013;5(1):22-33.
Klein C, Lammens A, Schäfer W, et al. Epitope interactions of monoclonal antibodies targeting CD20 and their relationship to functional properties. mAbs. 2013;5(1):22-33.
Honeychurch J, Alduaij W, Azizyan M, et al. Antibody-induced nonapoptotic cell death in human lymphoma and leukemia cells is mediated through a novel reactive oxygen species-dependent pathway. Blood. 2012;119(15):3523-3533.
Honeychurch J, Alduaij W, Azizyan M, et al. Antibody-induced nonapoptotic cell death in human lymphoma and leukemia cells is mediated through a novel reactive oxygen species-dependent pathway. Blood. 2012;119(15):3523-3533.
VENCLEXTA® (venetoclax tablets) Prescribing Information. North Chicago, IL: AbbVie Inc; 2019.
VENCLEXTA® (venetoclax tablets) Prescribing Information. North Chicago, IL: AbbVie Inc; 2019.
CALQUENCE® (acalabrutinib) Prescribing Information. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2019.
CALQUENCE® (acalabrutinib) Prescribing Information. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2019.
IMBRUVICA® (ibrutinib) Prescribing Information. Horsham, PA: Janssen Biotech, Inc.; 2019.
IMBRUVICA® (ibrutinib) Prescribing Information. Horsham, PA: Janssen Biotech, Inc.; 2019.
Goede V, Fischer K, Busch R, et al. Obinutuzumab plus chlorambucil in patients with CLL and coexisting conditions. N Engl J Med. 2014;370:1101-1110. doi:10.1056/NEJMoa1313984. Supplementary appendix: http://www.nejm.org/doi/suppl/10.1056/NEJMoa1313984/suppl_file/nejmoa1313984_appendix.pdf. Accessed February 9, 2016.
Goede V, Fischer K, Busch R, et al. Obinutuzumab plus chlorambucil in patients with CLL and coexisting conditions. N Engl J Med. 2014;370:1101-1110. doi:10.1056/NEJMoa1313984. Supplementary appendix: http://www.nejm.org/doi/suppl/10.1056/NEJMoa1313984/suppl_file/nejmoa1313984_appendix.pdf. Accessed February 9, 2016.
Data on file. Genentech, Inc.
Data on file. Genentech, Inc.
Howlader N, Noone AM, Krapcho M, et al, eds. SEER Cancer Statistics Review, 1975-2012. National Cancer Institute website. http://seer.cancer.gov/csr/1975_2012/results_merged/topic_med_age.pdf. Updated September 18, 2015. Accessed February 9, 2016.
Howlader N, Noone AM, Krapcho M, et al, eds. SEER Cancer Statistics Review, 1975-2012. National Cancer Institute website. http://seer.cancer.gov/csr/1975_2012/results_merged/topic_med_age.pdf. Updated September 18, 2015. Accessed February 9, 2016.
Thurmes P, Call T, Slager S, et al. Comorbid conditions and survival in unselected, newly diagnosed patients with chronic lymphocytic leukemia. Leuk Lymphoma. 2008;49(1):49-56.
Thurmes P, Call T, Slager S, et al. Comorbid conditions and survival in unselected, newly diagnosed patients with chronic lymphocytic leukemia. Leuk Lymphoma. 2008;49(1):49-56.
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