Additional restrictions and eligibility rules apply. 1/2

Patient's last name: First name: DOB: / / REQUIRED

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Street address: City: State: ZIP: Male Female Home phone: Cell phone: Email address:

Alternate contact name: Relationship: Alternate phone: Cell phone: Alternate email address: OK to leave message with alternate contact

2 PATIENT INFORMATION

1 BY COMPLETING THIS FORM, I request the following services on behalf of the patient:

Primary Medical Insurance Information

Commercial Medicare UninsuredCopy of insurance cards attached? Yes NoPrimary insurance (PI) company name: PI policy #: PI group #: PI phone #: Policyholder name:

Prescription Drug Insurance Information

Patient does not have prescription coverage. Rx insurance company name: Rx member ID #: Rx phone #: PCN: BIN: Rx group #: Rx policyholder name: Relationship to policyholder:

3 INSURANCE INFORMATION NOTE: Please include copy of front and back of insurance card.

Patient Diagnosis (ICD-10-CM)Renal cell carcinoma (RCC) C64 Malignant neoplasm of kidney, except renal pelvis C64.1 Malignant neoplasm of right kidney, except renal pelvis C64.2 Malignant neoplasm of left kidney, except renal pelvis C64.9 Malignant neoplasm of unspecified kidney, except renal pelvisHepatocellular carcinoma (HCC) C22.0 Liver cell carcinoma C22.8 Malignant neoplasm of liver, primary, unspecified as to typeOther

Diagnosis date: / /

Please check the line of therapy for CABOMETYX prescription: First-line treatment Second-line or subsequent treatment

Current medications:

Drug and non-drug allergies:

No known drug allergies

4 MEDICAL INFORMATION

Prescriber’s name: Street address: City: State: ZIP: Phone: Fax: State license #: Prescriber’s NPI #:

Office name: Specialty: Office contact’s name: Office contact’s phone: Office contact’s email: Group NPI #: Tax ID #:

5 PRESCRIBER INFORMATION

15-day Free Trial and EASE enrollment EASE enrollment only 15-day Free Trial only Patient Assistance Program (PAP) only

ENROLLMENT FORM & 15-DAY FREE TRIAL REQUEST

CALL: 1-844-900-EASE (1-844-900-3273)

Monday to Friday 8:00 am to 8:00 pm (ET)

FAX: 1-844-901-EASE (1-844-901-3273)

VISIT: www.EASE.US

Will dispense through IOD (in-office dispensing pharmacy)IOD contact’s name: IOD contact’s phone: Email:

Have EASE forward the prescription to the contracted or payer-mandated specialty pharmacy (SP) We have already sent the prescription to the following pharmacy:

6 PRESCRIPTION FULFILLMENT

(15-Day Free Trial limited to NEW patients only)

Please confirm patient is newly prescribed CABOMETYX Yes NoComplete prescription for the 15-day Free Trial Program. A free 15-day supply of CABOMETYX will be dispensed and shipped to the patient. Important: Please tell the patient to expect a call from McKesson Specialty Pharmacy to obtain his or her consent to ship.

CABOMETYX dose 60 mg tablets 40 mg tablets 20 mg tablets

DirectionsOnce daily

Quantity 15 tablets (per program guidelines)

Please attach a separate prescription if this section does not comply with your state's prescription laws.

Dispense as writtenPrescriber's full signature: Date: / /

Sign Here

7 15-DAY FREE TRIAL PRESCRIPTION*

8 PRESCRIPTION FOR CABOMETYX QUICK START PROGRAM* — FOR PAYER DELAYS(Quick Start limited to NEW patients only)

Please confirm patient is newly prescribed CABOMETYX Yes No

CABOMETYX dose 60 mg tablets 40 mg tablets 20 mg tablets

DirectionsOnce daily

Quantity 15 tablets (per program guidelines)

Authorize refills (up to 3 refills

per program guidelines)

Dispense as writtenPrescriber's full signature: Date: / /

In order for us to send medication to your patient, the prescription information below must be complete and accurate.

CABOMETYX dose 60 mg tablets 40 mg tablets 20 mg tablets

DirectionsOnce daily

Quantity 30 tablets tablets

Authorize refills refills

Please attach a separate prescription if this section does not comply with your state's prescription laws.

Please check 1 box and sign on the line above it.

Prescriber's full signature: Date: / / Dispense as written Substitution allowed

The prescriber is to comply with his/her state-specific prescription requirements such as e-prescribing, state-specific prescription form, language, etc. Non-compliance with state-specific requirements could result in outreach to the prescriber.

Sign Here

9 CABOMETYX PRESCRIPTION (Complete ONLY IF you need the prescription triaged to a specialty pharmacy or PAP)

Please see full Prescribing Information for CABOMETYX.

©2019 Exelixis, Inc. ACC-0076 01/19 2/2

*Limited to on-label indications. Additional restrictions and eligibility rules apply.

Patient's last name: First name: DOB: / / REQUIRED

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Sign Here

Sign Here

I certify that the patient and physician information contained in this enrollment form is complete and accurate to the best of my knowledge. I have prescribed CABOMETYX® based on my judgment of medical necessity and I will be supervising the patient’s treatment. I have received the necessary legal authorization from the patient to transmit the patient’s personal health information, as provided on this form, to EXELIXIS®, and parties working with EXELIXIS, so that they may (1) contact the patient at the patient’s phone number(s) provided on this form and (2) perform a preliminary assessment of insurance verification and determine patient eligibility for the EXELIXIS product program. I authorize the forwarding of this prescription to a dispensing specialty pharmacy on behalf of myself and the patient. I understand that neither I nor the patient may seek reimbursement for any free product received under the program. Please attach a separate prescription if this form does not comply with your state's prescription laws.

Prescriber's full signature: Date: / /

10 PRESCRIBER DECLARATION

ENROLLMENT FORM & 15-DAY FREE TRIAL REQUEST

Fax Completed and Signed Form to:

FAX: 1-844-901-EASE (1-844-901-3273)