Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need. Did you know that NeedyMeds has thousands of other free resources? Here’s a look at more ways we can help you save money on medicine and healthcare costs. Each one can be found under the “Patient Savings” tab on our website:

● Diagnosis-Based Assistance — NeedyMeds lists thousands of assistance programs for almost any health condition. If you are going through chemo treatment for cancer, there are programs that can help with wig costs and scalp-cooling products. We also list resources for free diabetes testing supplies, caregiver lodging support, and much more.

● Free, Low Cost, and Sliding Scale Clinics — This popular collection contains information on 16,000+ free, low cost, and sliding scale medical and dental clinics across the U.S. It’s a great resource if you need affordable medical treatment and don’t know where to go.

● Coupons, Rebates & More — You can use the NeedyMeds website to find nearly 2,000 cost-saving opportunities for both prescription and over-the-counter drugs and medical supplies.

● Medical Transportation — Need help getting to the doctor’s office or medical facility? You may be eligible for financial assistance if you meet certain requirements.

NeedyMeds also offers information on diagnosis-based camps and retreats, recreational programs, scholarships, government programs, $4 generic drug programs, and more. Finally, I want to tell you about the NeedyMeds Drug Discount Card. Thousands of people use this free, anonymous, and easy-to-use tool to get the best price on their medications. To date, our drug discount card has saved patients over $244,000,000. Check out the next page to learn more. Feel free to call our toll-free helpline if you have any questions. You can reach us at 1-800-503-6897 Monday-Friday, 9am-5pm Eastern Time. Thanks for using NeedyMeds! Please let us know if we can do anything else to help you afford the costs of your healthcare.

Rich Sagall, MD President, NeedyMeds

BIN: 019520RX PCN: NMEDSRX GRP: PDFPDFID: NMNA019309901930

This is a drug discount program, not an insurance plan.

Clip the card and save

• Save up to 80%

• Use at over 65,000 pharmacies nationwide including all major chains

• Share the card with friends and family

• Use the card as often as needed

• Free, no fees or registration

• Never expires

• A drug isn’t covered by your insurance

• Your insurance has no drug coverage

• You have a high drug deductible

What if I have insurance?Anyone can use the card, but it can’t be combined with insurance.

You can use the card instead of insurance if:

• You have met a low medicine cap

• The card offers a better price than your copay

• You are in the Medicare Part D donut hole

What drugs are covered?The card is good for prescription drugs, over-the-counter medicines and medical

supplies if written on a prescription blank, and pet prescription medicinespurchased at a pharmacy. You’ll save on most, but not all, prescriptions.

The card is not valid in combination with other insurance plans, including Medicare, Medicaid or any state or federal prescription insurance. The card can be used only if

you decide not to use your government-sponsored drug plan for your purchases.

Patient: Simply present this card to a participating pharmacy to receive a discount on your prescription. Patients who have Medicare, including Part D, Medicaid or any state or federal prescription insurance can only use this card if they choose not to use their government-sponsored drug plan for their purchase. The card is not valid in combination with those programs. For questions concerning the card, call 1-888-602-2978 or visit www.drugdiscountcardinfo.com.Pharmacist: Card must be presented to receive program benefits. Clear system of prior cardholder information associated with this universal cardholder ID. For processing questions, call Argus Health Systems at 1-866-921-7286.

NeedyMeds Drug Discount Cardwww.needymeds.org

DRUG DISCOUNT CARD

NeedyMedsNeedyMeds.org

To obtain a plastic drug discount card, send a self-addressed stamped envelope to:

NeedyMeds-PAPPO Box 219

Gloucester, MA 01931

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.

Insurance Information Step 2:

No Insurance

Primary insurance name:

Phone: ( ) - Subscriber name:

Subscriber/Policy ID #:

Group #:

ORAL PRODUCTS Refer Patient to Co-pay Assistance GATCF† Patient Assistance

Required field (*) ACS/062315/0110(3) 11/17

Last name*: First name*: DOB*: / / Gender: M F

Street*: City*: State*: ZIP*:

Home phone: ( ) - Work/cell: ( ) - OK to contact patient for additional information? Yes No

Patient preferred language:

Alternate contact name: Relationship: Alternate phone: ( ) -

Patient InformationStep 1:

Statement of Medical Necessity (SMN)SUBMIT SMN AND PAN FORMS ONLYPhone: (888) 249-4918 Fax: (877) 313-2659

Genentech-Access.com/BioOncology

Prescriber InformationStep 3:

Last name*: First name*:

Practice name*:

Street*: Suite #: City*: State*: ZIP*:

Prescriber tax ID #: Prescriber NPI‡ #: Group NPI #:

Office contact: Office contact phone: ( ) - Fax: ( ) -

To the highest level of specificity, provide:

Primary diagnosis code*: Has treatment started? Yes No

Date of treatment: / /

Secondary diagnosis code:

PHARMACY AND SHIPPING INFORMATION

Specialty pharmacy Yes No

Preferred specialty pharmacy:

Onsite pharmacy Yes No

Onsite pharmacy:

Ship to: Patient Practice Other:

Diagnosis CodeStep 4:

*Required field. Genentech BioOncology Access Solutions cannot process your SMN unless these fields are completed. †Genentech® Access to Care Foundation. ‡ National Provider Identifier. 1/3

Indicate the patient’s therapy*: ALECENSA® (alectinib) COTELLIC® (cobimetinib) Erivedge® (vismodegib) Tarceva® (erlotinib) ZELBORAF® (vemurafenib)

Secondary insurance name:

Phone: ( ) - Subscriber name:

Subscriber/Policy ID #:

Group #:

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.)

*Required field. Genentech BioOncology® Access Solutions cannot process your SMN unless these fields are completed.

REMINDER: This form cannot be processed without a prescriber’s signature and date, as well as a signed and dated PAN form.

2/3

Unresectable/metastatic melanoma?* Yes No Other Confirmed positive for BRAF V600E?* Yes No

ZELBORAF prescription 960 mg twice a day Other: Dispense: -month supply Refill times

For ZELBORAF® (vemurafenib) patients:

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.

Sign and Date FormStep 6:

Prescription Information for PatientStep 5:

Required field (*)

Last name*: First name*: DOB*: / /

For ALECENSA® (alectinib) patients:

Metastatic non-small cell lung cancer (NSCLC)?* Yes NoConfirmed positive for anaplastic lymphoma kinase (ALK)?* Yes No

ALECENSA prescription 600 mg twice daily Other: Dispense: -month supply Refill times

ALECENSA SureStart® free starter supply 600 mg twice daily Dispense: 1-month supply Refill times

For Tarceva® (erlotinib) patients:

Treatment of patients with metastatic non-small cell lung cancer (NSCLC) whose tumors have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations?* Yes No Advanced pancreatic cancer and have not received chemotherapy?* Yes No

Tarceva prescription 150 mg daily 100 mg daily Other: mg daily Dispense: -month supply Refill times

For COTELLIC® (cobimetinib) patients:

Unresectable/metastatic melanoma?* Yes No Used in combination with ZELBORAF® (vemurafenib)?* Yes No (If yes, complete ZELBORAF section below.)Confirmed positive for: BRAF V600E?* Yes No BRAF V600K?* Yes No

COTELLIC prescription 60 mg daily for 21 consecutive days on, followed by a 7-day rest period Other: Dispense: -month supply Refill times

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

Erivedge prescription 150 mg daily Other: Dispense: -month supply Refill times

For Erivedge® (vismodegib) patients:

Tarceva SureStart® free starter supply 150 mg daily 100 mg dailyDispense: 15-day supply Refill times

ONCE you've completed the form

Be sure your patient signs and dates the Patient Authorization and Notice of Release of Information (PAN)

Submit both forms to Genentech BioOncology Access Solutions

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

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.)

*Required field. Genentech BioOncology® Access Solutions cannot process your SMN unless these fields are completed.

REMINDER: This form cannot be processed without a prescriber’s signature and date, as well as a signed and dated PAN form.

2/3

Unresectable/metastatic melanoma?* Yes No Other Confirmed positive for BRAF V600E?* Yes No

ZELBORAF prescription 960 mg twice a day Other: Dispense: -month supply Refill times

For ZELBORAF® (vemurafenib) patients:

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.

Sign and Date FormStep 6:

Prescription Information for PatientStep 5:

Required field (*)

Last name*: First name*: DOB*: / /

For ALECENSA® (alectinib) patients:

Metastatic non-small cell lung cancer (NSCLC)?* Yes NoConfirmed positive for anaplastic lymphoma kinase (ALK)?* Yes No

ALECENSA prescription 600 mg twice daily Other: Dispense: -month supply Refill times

ALECENSA SureStart® free starter supply 600 mg twice daily Dispense: 1-month supply Refill times

For Tarceva® (erlotinib) patients:

Treatment of patients with metastatic non-small cell lung cancer (NSCLC) whose tumors have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations?* Yes No Advanced pancreatic cancer and have not received chemotherapy?* Yes No

Tarceva prescription 150 mg daily 100 mg daily Other: mg daily Dispense: -month supply Refill times

For COTELLIC® (cobimetinib) patients:

Unresectable/metastatic melanoma?* Yes No Used in combination with ZELBORAF® (vemurafenib)?* Yes No (If yes, complete ZELBORAF section below.)Confirmed positive for: BRAF V600E?* Yes No BRAF V600K?* Yes No

COTELLIC prescription 60 mg daily for 21 consecutive days on, followed by a 7-day rest period Other: Dispense: -month supply Refill times

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

Erivedge prescription 150 mg daily Other: Dispense: -month supply Refill times

For Erivedge® (vismodegib) patients:

Tarceva SureStart® free starter supply 150 mg daily 100 mg dailyDispense: 15-day supply Refill times

STEPS for Completing the SMN for Oral Genentech BioOncology® ProductsSUBMIT SMN AND PAN FORMS ONLY

3/3

Genentech-Access.com/BioOncology Phone: (888) 249-4918 Fax: (877) 313-2659Tarceva® is a registered trademark of OSI Pharmaceuticals, LLC, an affiliate of Astellas Pharma US, Inc.

ALECENSA® is a registered trademark of Chugai Pharmaceutical Co., Ltd., Tokyo, Japan.

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

©2017 Genentech USA, Inc. So. San Francisco, CA All rights reserved. ACS/062315/0110(3) 11/17 Printed in USA

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 preferences (if applicable). Required field.

Step 3:

Provide information about your practice.

Step 5:

Complete the Prescription Information section for the oral Genentech BioOncology product you wish to prescribe and review optional SureStart® free starter supply.

Step 6:

Sign and date the form. Please write legibly.

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.

Insurance Information Step 2:

No Insurance

Primary insurance name:

Phone: ( ) - Subscriber name:

Subscriber/Policy ID #:

Group #:

ORAL PRODUCTS Refer Patient to Co-pay Assistance GATCF† Patient Assistance

Required field (*) ACS/062315/0110(3) 11/17

Last name*: First name*: DOB*: / / Gender: M F

Street*: City*: State*: ZIP*:

Home phone: ( ) - Work/cell: ( ) - OK to contact patient for additional information? Yes No

Patient preferred language:

Alternate contact name: Relationship: Alternate phone: ( ) -

Patient InformationStep 1:

Statement of Medical Necessity (SMN)SUBMIT SMN AND PAN FORMS ONLYPhone: (888) 249-4918 Fax: (877) 313-2659

Genentech-Access.com/BioOncology

Prescriber InformationStep 3:

Last name*: First name*:

Practice name*:

Street*: Suite #: City*: State*: ZIP*:

Prescriber tax ID #: Prescriber NPI‡ #: Group NPI #:

Office contact: Office contact phone: ( ) - Fax: ( ) -

To the highest level of specificity, provide:

Primary diagnosis code*: Has treatment started? Yes No

Date of treatment: / /

Secondary diagnosis code:

PHARMACY AND SHIPPING INFORMATION

Specialty pharmacy Yes No

Preferred specialty pharmacy:

Onsite pharmacy Yes No

Onsite pharmacy:

Ship to: Patient Practice Other:

Diagnosis CodeStep 4:

*Required field. Genentech BioOncology Access Solutions cannot process your SMN unless these fields are completed. †Genentech® Access to Care Foundation. ‡ National Provider Identifier. 1/3

Indicate the patient’s therapy*: ALECENSA® (alectinib) COTELLIC® (cobimetinib) Erivedge® (vismodegib) Tarceva® (erlotinib) ZELBORAF® (vemurafenib)

Secondary insurance name:

Phone: ( ) - Subscriber name:

Subscriber/Policy ID #:

Group #: