Fax Completed Form and Required Documents to (240)250-2520

Call Us at (240)685-6949 Email us at administration@allyinfusion.com or Visit us at www.allyinfusion.com

Patient Name: DOB:

Ocrevus Referral Form

Required Documents (Please Fax)

1. Demographic and Insurance Information-- a copy of the front and back of the card, and subscribersinformation and relationship to the patient

2. Three to six months of most recent clinicals/office notes (To include other therapies tried and failed), aswell as studies supporting diagnosis (MRI, CT, Muscle Biopsy, EMG, etc.)

3. Hepatitis B testing

4. Please complete Ocrevus enrollment forms and fax a copy to both Genetech and Ally (240)250-2520.

Patient Data

Allergies Height Weight

Diagnosis: Multiple Sclerosis (G35) Other (include ICD-10)_______

RRMS PPMS SPMS PRMS

Prescription

Prescription orders: Ocrevus (Ocrelizumab, each vial contains 300mg/10ml) Initial Course: __________300mg IV on days 0 and 15 Maintenance Course: _________600mg IV every _________ months _____ Refills Initial Course Premedication (Required) Solumedrol 250mg Maintenance Course Premedication (Required) Solumedrol 250mg

Other: _____________________________________________________________ _____ Refills

Pre-medication: Acetaminophen 650mg PO* Diphenhydramine 25mg PO Diphenhydramine 25mg IVP Acetaminophen 1000mg PO Diphenhydramine 50mg PO Diphenhydramine 50mg IVP* Ibuprofen 400mg PO Loratadine 10mg PO Solu-medrol 40mg IVP Other:________________ * Manufacturer Recommendtions

Physician Name License# NPI# Phone Fax

Physician Signature Date

Diagnosis code*: G35 Multiple Sclerosis (MS) Relapsing Multiple Sclerosis (RMS) Primary Progressive Multiple Sclerosis (PPMS)

Other diagnosis code:

Has the patient started prescribed OCREVUS™ (ocrelizumab)? Yes No Anticipated date of treatment: / / Current/most recent MS therapy:

INFUSION AND DRUG ACQUISITION INFORMATIONSpecialty pharmacy: Yes No Preferred specialty pharmacy: Place of infusion (check all that apply): Prescribing physician’s office Other (complete infusion site details below)

Infusion site NPI #: Infusion site name: Infusion site tax ID #: Street: Suite #: City: State: ZIP: Phone: ( ) - Ship to: Prescribing physician’s office Infusion site above Other address:

NO INSURANCE ENROLL PATIENT IN BENEFITS REVERIFICATION (Please see page 2 for additional program details.)

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

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

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

Last name*: First name*: DOB*: / / Gender: M F Street: City: State*: ZIP: Home phone: ( ) - OK to contact patient for additional information? Yes No Patient preferred language:Alternate contact name: Relationship: Alternate phone: ( ) -

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

Statement of Medical Necessity (SMN)PLEASE DO NOT SEND ANY ADDITIONAL DOCUMENTATION.

Phone: (800) 888-2882 Fax: (877) 312-2193

*Required field. †Genentech® Access to Care Foundation. ‡National Provider Identifier.

Refer Patient to Co-pay Assistance GATCF† Patient Assistance

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, infusion site of care 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 directly to the patient or an alternative site of care. I request Genentech Access Solutions convey to the pharmacy or alternative site of administration 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.

STEP 1: Patient Information

STEP 2: Insurance Information

STEP 3: Prescriber Information

STEP 4: Diagnosis Code and Clinical Information

OCREVUS STARTER PROGRAM FREE STARTER SUPPLY Initial dose: SIG: Dispense 1 300-mg vial Refills: 1Please see page 2 for additional starter program details.By checking above I acknowledge that for my patient to be eligible forthe OCREVUS Starter Program a PA must be submitted (if required)and payer determination must be pending. I agree that neither I nor theinfusion site of care will seek reimbursement for the free product providedunder this program.

OCREVUS PRESCRIPTION Initial Dose: Initial dose SIG: Dispense 300-mg vials Refills:Instructions:

Subsequent Dose: Subsequent dose SIG: Dispense 300-mg vials Refills:Instructions:

Genentech-Access.com/OCREVUSRequired field (*) ACS/051116/0082 11/16

Page 1 of 3

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

Sign anddate here

S:8.5"S:11"

T:8.5"T:11"

B:8.75"B:11.25"

©2016 Genentech USA, Inc. So. San Francisco, CA All rights reserved. ACS/051116/0082 11/16 Printed in USA

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

ONCE you've completed the form

OCREVUS™ and its logo are trademarks and the Access Solutions logo is a registered trademark of Genentech, Inc.

Diagnosis code*: G35 Multiple Sclerosis (MS) Relapsing Multiple Sclerosis (RMS) Primary Progressive Multiple Sclerosis (PPMS) Other diagnosis code:

Has the patient started prescribed OCREVUS™ (ocrelizumab)? Yes No Anticipated date of treatment: / / Current/most recent MS therapy:

INFUSION AND DRUG ACQUISITION INFORMATIONSpecialty pharmacy: Yes No Preferred specialty pharmacy: Place of infusion (check all that apply): Prescribing physician’s office Other (complete infusion site details below) Infusion site name: Infusion site tax ID #: Infusion site NPI #: Street: Suite #: City: State: ZIP: Phone: ( ) - Ship to: Prescribing physician’s office Infusion site above Other address:

NO INSURANCE ENROLL PATIENT IN BENEFITS REVERIFICATION (Please see page 2 for additional program details.)

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

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

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

Last name*: First name*: DOB*: / / Gender: M F Street: City: State*: ZIP: Home phone: ( ) - OK to contact patient for additional information? Yes No Patient preferred language: Alternate contact name: Relationship: Alternate phone: ( ) -

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

Statement of Medical Necessity (SMN)PLEASE DO NOT SEND ANY ADDITIONAL DOCUMENTATION.

Phone: (800) 888-2882 Fax: (877) 312-2193

*Required field. †Genentech® Access to Care Foundation. ‡National Provider Identifier.

Refer Patient to Co-pay Assistance GATCF† Patient Assistance

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, infusion site of care 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 directly to the patient or an alternative site of care. I request Genentech Access Solutions convey to the pharmacy or alternative site of administration 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.

STEP 1: Patient Information

STEP 2: Insurance Information

STEP 3: Prescriber Information

STEP 4: Diagnosis Code and Clinical Information

OCREVUS STARTER PROGRAM FREE STARTER SUPPLY Initial dose: SIG: Dispense 1 300-mg vial Refills: 1 Please see page 2 for additional starter program details. By checking above I acknowledge that for my patient to be eligible for the OCREVUS Starter Program a PA must be submitted (if required) and payer determination must be pending. I agree that neither I nor the infusion site of care will seek reimbursement for the free product provided under this program.

OCREVUS PRESCRIPTION Initial Dose: Initial dose SIG: Dispense 300-mg vials Refills: Instructions:

Subsequent Dose: Subsequent dose SIG: Dispense 300-mg vials Refills: Instructions:

Genentech-Access.com/OCREVUSRequired field (*) ACS/051116/0082 11/16

Page 1 of 3

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

Sign anddate here

S:8.5"

S:11"

T:8.5"

T:11"

B:8.75"

B:11.25"

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 3:

Provide information about your practice.

Step 4:

Complete the appropriate diagnosis code and include the indication if known. Required field.

Step 5:

Complete the OCREVUS prescription information.

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

Submit both forms to OCREVUS Access Solutions

Submit prior authorization (PA) to the patient’s health insurance plan, if required

Page 2 of 3

Contact OCREVUS Access Solutions if you have any questions.

Call: (800) 888-2882 Visit: Genentech-Access.com/OCREVUS

Step 6:

Sign and date the form. Please write legibly. We can't provide services until the form is signed and dated.

S:8.5"S:11"

T:8.5"T:11"

B:8.75"B:11.25"

STATEMENT OF MEDICAL NECESSITY (SMN)Please write legibly and complete all required fields (*) to prevent delays. If you would like to complete this form online via My Patient Solutions™, our online patient management tool, visit Genentech-Access.com/OCREVUS to register for My Patient Solutions.

PATIENT SERVICES By completing this form, I am requesting services on behalf of the patient, which may include benefits investigation,

navigating the prior authorization process and appeals support. If you require GATCF services or co-pay support, please check the appropriate boxes on behalf of your patient, as these services cannot be performed without your specific request

INSURANCE INFORMATION Patient must have signed the Patient Authorization and Notice of Release of Information (PAN) form, indicating they have

given OCREVUS Access Solutions permission to contact them directly for missing or additional information

Benefits reverification: By enrolling my patient in this service, OCREVUS Access Solutions will perform a benefits investigation approximately 6 weeks prior to patient's next treatment date.

DIAGNOSIS CODE AND CLINICAL INFORMATION Enter the Diagnosis Code to the highest level of specificity

INFUSION AND DRUG ACQUISITION INFORMATION Check the appropriate box to indicate the need for a specialty pharmacy to dispense OCREVUS™ (ocrelizumab).

OCREVUS Access Solutions will verify with your patient’s insurance plan whether a specialty pharmacy is in network

PRESCRIPTION Complete the dose and refill fields only if you are planning to use a specialty pharmacy to acquire OCREVUS for your

patient, or if you are requesting GATCF assistance for your patient

OCREVUS STARTER PROGRAM The OCREVUS Starter Program provides eligible, naive patients with a one-time free trial supply of OCREVUS. There is

no purchase obligation by virtue of a patient’s receipt of the free one-time supply. Requests for the OCREVUS Starter Program trial cannot be processed without a completed and signed 1) OCREVUS Statement of Medical Necessity (SMN) form and 2) OCREVUS Patient Authorization and Notice of Release of Information (PAN) form. Patients must have an on-label prescription for OCREVUS, consistent with the FDA-approved label for OCREVUS, and satisfy all other enrollment criteria to qualify. Free product via the OCREVUS Starter Program trial will be available through OCREVUS Access Solutions. I understand that neither the prescriber, site of care, the pharmacies, nor any patients receiving free product via the OCREVUS Starter Program trial may seek reimbursement or credit for all or any part of the product received by the patient through this offer from any insurer, health plan, or government program

The OCREVUS Starter Program for OCREVUS cannot be counted towards any out-of-pocket costs under any plan (such as true out-of-pocket cost [TrOOP] under a Medicare Part D prescription drug plan). Prescribers may not advertise or otherwise use the program as a means of promoting their services or Genentech’s products to patients. This program is void where prohibited by law and may not be used in or by residents of restricted states, if applicable. This product is intended solely for use for named patient. Free Genentech product may not be sold, purchased or traded or offered for sale, purchase or trade. If coverage is approved prior to administration of this product, please contact Genentech prior to administration of this product. This program is not a benefit plan. Genentech reserves the right to discontinue or modify the terms of this program at any time, without notice

PRESCRIBER SIGNATURE This form cannot be processed without an original signature

PROVIDING ADDITIONAL DOCUMENTS OR INFORMATION WITH THIS FORM, OTHER THAN WHAT IS REQUESTED, WILL DELAY PROCESSING.

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

Genentech-Access.com/OCREVUSPhone: (800) 888-2882 Fax: (877) 312-2193

OCREVUS™ and its logo are trademarks and the Access Solutions logo is a registered trademark of Genentech, Inc.

ATTACH TO COMPLETED SMN Attach a signed and dated PAN form. OCREVUS Access Solutions and/or GATCF cannot work with the insurance

plan on your patient’s behalf without a signed and dated PAN form

© 2016 Genentech USA, Inc. So. San Francisco, CA All rights reserved. ACS/051116/0082 11/16 Printed in USA

Page 3 of 3

S:8.5"S:11"

T:8.5"T:11"

B:8.75"B:11.25"