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Patient Assistance Information

 
2 Programs for Lucentis Injection
 
 
Genentech Access to Care Foundation (Lucentis)

PO Box 2807
San Francisco, CA 94083
Phone : 800-232-0592
Fax: 888-727-7773
Eligibility
> This program is intended for patients with no prescription coverage or have been denied coverage. Medicare PartD is determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider
Who Can Apply
> Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms. Application is received via fax, mail or download from website. Return application via fax or mail.
Required
> Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form available on website, attach proof of income.
Supply
> Amount/supply varies. Refill process and limit not specified. New application is to be completed yearly.
Ship To
> Ship to Doctor's office, hospital, or pharmacy.
Note
> This program also provides copay assistance. Contact program for Spanish application.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Lucentis Injection
 
 
 
Patient Access Network Foundation (PAN)

PO Box 221858
Charlotte, NC 28222
Phone : (866)316-7263
Fax: (866)316-7263
Eligibility
> This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US.
Who Can Apply
> Patients or healthcare providers can complete the application online or by phone.
Required
> Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received.
Supply
> Not applicable
Ship To
> Patient sent card to be used at pharmacy
Note
> *Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Lucentis Injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader