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.; 2022.
GAZYVA full Prescribing Information. South San Francisco, CA: Genentech, Inc.; 2022.
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.
IIMBRUVICA® (ibrutinib) Prescribing Information. Horsham, PA: Janssen Biotech, Inc.; 2019.
IIMBRUVICA® (ibrutinib) Prescribing Information. Horsham, PA: Janssen Biotech, Inc.; 2019.
Data on file. Genentech, Inc.
Data on file. Genentech, Inc.
Canales M, Buchholz T, Izutsu K, et al. Obinutuzumab short duration infusion in previously untreated advanced follicular lymphoma: results from the end of induction analysis of the phase IV GAZELLE study. Presented at ASCO 2021.
Canales M, Buchholz T, Izutsu K, et al. Obinutuzumab short duration infusion in previously untreated advanced follicular lymphoma: results from the end of induction analysis of the phase IV GAZELLE study. Presented at ASCO 2021.
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