BY COMPLETING THIS FORM, I am requesting services on behalf of the patient, which may include benefits investigation, help navigating the prior authorization (PA) process and appeals support.

Refer Patient to Co-pay Assistance GATCF† Patient Assistance

Required field (*) ACS/062315/0111(2) 12/17

*Required field. †Genentech® Access to Care Foundation. ‡National Provider Identifier. §Required to the highest level of specificity.

Last name*: First name*: DOB*: / / Gender: M F Street*: City*: State*: ZIP*: Home phone: ( ) - Work/cell: ( ) - OK to contact patient for additional information? Yes NoPatient preferred language (if other than English): Alternate contact name: Relationship: Alternate phone: ( ) -

Patient InformationStep 1:

Insurance InformationStep 2:

Sign and date here, then fax to (877) 313-2659

Prescriber’s Signature*: Date*: / / (Original signature required. This form cannot be processed without a prescriber’s signature.)

PHYSICIAN CERTIFICATION: By signing below, I certify: (a) the above therapy is medically necessary, (b) I received the authorization to release the information above and other protected health information (as defined by the Health Insurance Portability and Accountability Act of 1996 [HIPAA]) to Genentech, Inc., Genentech Access Solutions, the contracted dispensing pharmacy, or other contractors for the purpose of requesting reimbursement support, assisting in initiating or continuing therapy and/or the evaluation of the patient’s eligibility for GATCF, as a break in treatment would negatively impact the patient’s therapeutic outcome and (c) I will not attempt to seek reimbursement for free product provided to the patient. I request Genentech Access Solutions convey to the pharmacy chosen by the above-named patient the prescription described herein.I agree to comply with the Genentech, Inc. program guidelines and understand that GATCF, at its sole discretion, reserves the right to modify or discontinue the program at any time and to verify the accuracy of the information submitted. I further understand that Genentech will provide vial replacement in a configuration that will create the least wastage. If applying for GATCF, I certify that (a) this patient has no medical insurance coverage or otherwise meets the financial criteria for the prescribed therapy, and is not eligible for other product financial support programs, and (b) the therapy identified above will not be used in a clinical trial. Note: Prescribers in all states must follow applicable law for a valid prescription and who is considered an authorized prescriber. For prescribers in states with official prescription form requirements, such as New York, please submit prescriptions on an official state prescription blank along with this form.Unapproved Use Warning: Please read the FDA-approved label for Genentech products before prescribing. If the indication for which you are prescribing a Genentech product is not listed in the FDA-approved label, you are prescribing the medication for an “unapproved” use, meaning that the FDA has not approved the efficacy, dosage amount or safety of this medication when used for such a use. Nevertheless, GATCF will consider providing the medication for your patient with this admonition, based upon your medical order, within program requirements.

Statement of Medical Necessity (SMN)PLEASE DO NOT SEND ANY ADDITIONAL DOCUMENTATION. Phone: (888) 249-4918 Fax: (877) 313-2659

Genentech-Access.com/Erivedge

No Insurance Primary insurance name: Phone: ( ) - Subscriber name: Subscriber/Policy ID #: Group #:

Secondary insurance name: Phone: ( ) - Subscriber name: Subscriber/Policy ID #: Group #:

Diagnosis Code and Erivedge Prescription InformationStep 4:

Last name*: First name*: Practice name*: Street*: Suite #: City*: State*: ZIP*: Prescriber tax ID #: Prescriber NPI‡ #: Group NPI #: Office contact: Office contact phone: ( ) - Fax: ( ) -

Prescriber InformationStep 3:

Specialty pharmacy: Yes No Preferred specialty pharmacy: Onsite pharmacy: Yes No Onsite pharmacy: Ship to: Patient Practice Other:

PHARMACY AND SHIPPING INFORMATION

Sign and Date FormStep 5:

Erivedge® (vismodegib) capsule 150 mg 150 mg daily Other: Dispense: -month supply Refill times

To the highest level of specificity, provide*: Primary diagnosis code§: Secondary diagnosis code§:

Metastatic basal cell carcinoma?* Yes No

Locally advanced basal cell carcinoma recurred following surgery, or not a candidate for surgery, and not a candidate for radiation?* Yes No

Erivedge®, its logo and the Access Solutions logo are registered trademarks of Genentech, Inc.

STEPS for Completing the Erivedge SMNPLEASE DO NOT SEND ANY ADDITIONAL DOCUMENTATION.

Step 1:

Fill out the patient’s personal information.

Step 2:

Provide the patient’s insurance information. If the patient does not have insurance, please check the "No Insurance" box.

Step 4:

Complete the appropriate diagnosis code and pharmacy preference, if applicable. Required field.

Step 3:

Provide information about your practice.

Step 5:

Sign and date the form. Please write legibly.

Contact Erivedge Access Solutions if you have any questions or need the most recent list of SPs.

Call: (888) 249-4918 Visit: Genentech-Access.com/Erivedge

Sample diagnosis code: C44.01 Basal cell carcinoma of skin of lip C44.111 Basal cell carcinoma of skin of unspecified eyelid, including canthus C44.112 Basal cell carcinoma of skin of right eyelid, including canthus C44.119 Basal cell carcinoma of skin of left eyelid, including canthus C44.211 Basal cell carcinoma of skin of unspecified ear and external auricular canal C44.212 Basal cell carcinoma of skin of right ear and external auricular canal C44.219 Basal cell carcinoma of skin of left ear and external auricular canal C44.310 Basal cell carcinoma of skin of unspecified parts of face C44.311 Basal cell carcinoma of skin of nose C44.319 Basal cell carcinoma of skin of other parts of face C44.41 Basal cell carcinoma of skin of scalp and neck C44.510 Basal cell carcinoma of anal skin C44.511 Basal cell carcinoma of skin of breast C44.519 Basal cell carcinoma of skin of other part of trunk C44.611 Basal cell carcinoma of skin of unspecified upper limb, including shoulder C44.612 Basal cell carcinoma of skin of right upper limb, including shoulder C44.619 Basal cell carcinoma of skin of left upper limb, including shoulder C44.711 Basal cell carcinoma of skin of unspecified lower limb, including hip C44.712 Basal cell carcinoma of skin of right lower limb, including hip

C44.719 Basal cell carcinoma of skin of left lower limb, including hip C44.81 Basal cell carcinoma of overlapping sites of skin C44.91 Basal cell carcinoma of skin, unspecified

These codes are not all-inclusive; appropriate codes can vary by patient, setting of care and payer. Correct coding is the responsibility of the provider submitting the claim for the item or service. Please check with the payer to verify codes and special billing requirements. Genentech does not make any representation or guarantee concerning reimbursement or coverage for any service or item.

Many payers will not accept unspecified codes. If you use an unspecified code, please check with your payer.

ONCE you’ve completed the form

Be sure your patient signs and dates the PAN

Submit both forms to Erivedge Access Solutions(877) 313-2659

Submit PA to the patient’s health insurance plan, if required

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

©2017 Genentech USA, Inc. So. San Francisco, CA All rights reserved. ACS/062315/0111(2) 12/17 Printed in USA

BY COMPLETING THIS FORM, I am requesting services on behalf of the patient, which may include benefits investigation, help navigating the prior authorization (PA) process and appeals support.

Refer Patient to Co-pay Assistance GATCF† Patient Assistance

Required field (*) ACS/062315/0111(2) 12/17

*Required field. †Genentech® Access to Care Foundation. ‡National Provider Identifier. §Required to the highest level of specificity.

Last name*: First name*: DOB*: / / Gender: M F Street*: City*: State*: ZIP*: Home phone: ( ) - Work/cell: ( ) - OK to contact patient for additional information? Yes NoPatient preferred language (if other than English): Alternate contact name: Relationship: Alternate phone: ( ) -

Patient InformationStep 1:

Insurance InformationStep 2:

Sign and date here, then fax to (877) 313-2659

Prescriber’s Signature*: Date*: / / (Original signature required. This form cannot be processed without a prescriber’s signature.)

PHYSICIAN CERTIFICATION: By signing below, I certify: (a) the above therapy is medically necessary, (b) I received the authorization to release the information above and other protected health information (as defined by the Health Insurance Portability and Accountability Act of 1996 [HIPAA]) to Genentech, Inc., Genentech Access Solutions, the contracted dispensing pharmacy, or other contractors for the purpose of requesting reimbursement support, assisting in initiating or continuing therapy and/or the evaluation of the patient’s eligibility for GATCF, as a break in treatment would negatively impact the patient’s therapeutic outcome and (c) I will not attempt to seek reimbursement for free product provided to the patient. I request Genentech Access Solutions convey to the pharmacy chosen by the above-named patient the prescription described herein.I agree to comply with the Genentech, Inc. program guidelines and understand that GATCF, at its sole discretion, reserves the right to modify or discontinue the program at any time and to verify the accuracy of the information submitted. I further understand that Genentech will provide vial replacement in a configuration that will create the least wastage. If applying for GATCF, I certify that (a) this patient has no medical insurance coverage or otherwise meets the financial criteria for the prescribed therapy, and is not eligible for other product financial support programs, and (b) the therapy identified above will not be used in a clinical trial. Note: Prescribers in all states must follow applicable law for a valid prescription and who is considered an authorized prescriber. For prescribers in states with official prescription form requirements, such as New York, please submit prescriptions on an official state prescription blank along with this form.Unapproved Use Warning: Please read the FDA-approved label for Genentech products before prescribing. If the indication for which you are prescribing a Genentech product is not listed in the FDA-approved label, you are prescribing the medication for an “unapproved” use, meaning that the FDA has not approved the efficacy, dosage amount or safety of this medication when used for such a use. Nevertheless, GATCF will consider providing the medication for your patient with this admonition, based upon your medical order, within program requirements.

Statement of Medical Necessity (SMN)PLEASE DO NOT SEND ANY ADDITIONAL DOCUMENTATION. Phone: (888) 249-4918 Fax: (877) 313-2659

Genentech-Access.com/Erivedge

No Insurance Primary insurance name: Phone: ( ) - Subscriber name: Subscriber/Policy ID #: Group #:

Secondary insurance name: Phone: ( ) - Subscriber name: Subscriber/Policy ID #: Group #:

Diagnosis Code and Erivedge Prescription InformationStep 4:

Last name*: First name*: Practice name*: Street*: Suite #: City*: State*: ZIP*: Prescriber tax ID #: Prescriber NPI‡ #: Group NPI #: Office contact: Office contact phone: ( ) - Fax: ( ) -

Prescriber InformationStep 3:

Specialty pharmacy: Yes No Preferred specialty pharmacy: Onsite pharmacy: Yes No Onsite pharmacy: Ship to: Patient Practice Other:

PHARMACY AND SHIPPING INFORMATION

Sign and Date FormStep 5:

Erivedge® (vismodegib) capsule 150 mg 150 mg daily Other: Dispense: -month supply Refill times

To the highest level of specificity, provide*: Primary diagnosis code§: Secondary diagnosis code§:

Metastatic basal cell carcinoma?* Yes No

Locally advanced basal cell carcinoma recurred following surgery, or not a candidate for surgery, and not a candidate for radiation?* Yes No

12/17