Don't qualify for this program?
Visit the DBAs to look for financial assistance based on your diagnosis.

Program 1 of 3.
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Updated April 16, 2014
Lucentis

Genentech Access to Care Foundation (Lucentis)

This program provides brand name medications at no or low cost.

Provided by: Genentech, Inc.

P.O. Box 2807
South San Francisco, CA 94083-2807

TEL: 800-232-0592


ALT PHONE:
FAX: 888-727-7773
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website
 

Patient Assistance Applications

Genentech Patient Auth. and Notice of Release of Information (PAN); Lucentis

Genentech Patient Auth. and Notice of Release of Information (PAN); Lucentis (Spanish)

Genentech Statement of Medical Necessity; Lucentis

Genentech Insurance Attestation-HCP Form; Lucentis

Genentech Financial Attestation Form; Lucentis

Genentech Confirmation of Infusion or Injection Form; Lucentis

 

Medications

  • Lucentis Injection 10mg/mL (ranibizumab)
 

Eligibility Requirements

Insurance Status Must have no prescription coverage or been denied coverage
Those with Part D Eligible? No
Income Gross annual household income at or below $100,000
Diagnosis/Medical Criteria Not disclosed
US Residency Required? Must be treated by US licensed healthcare provider
   

Application

Obtaining Doctor/Doctors office starts process by filling out enrollment/statement of medical necessity forms
Receiving Faxed, mailed or downloaded from website
Returning Mail or fax
Doctor's Action Complete and sign statement of medical necessity
Applicant's Action Complete Patient Authorization and Notice of Information Form available on website, attach proof of income
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Doctor's office, hospital, or pharmacy
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application New application yearly
   

Additional Information

This program also provides copay assistance.

Contact program for Spanish application.



Don't qualify for this program?
Visit the DBAs to look for financial assistance based on your diagnosis.

Program 2 of 3.
Scroll down to see them all.
Updated March 04, 2014
Lucentis

HealthWell Foundation Copay Program

This is a copay assistance program.

Provided by: HealthWell Foundation

P.O Box 4133
Gaithersburg, MD 20897-7811

TEL: 800-675-8416


ALT PHONE:
FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website
 

Patient Assistance Applications

Reimbursement Request Form - Copayment Assistance

 

Medications

  • Lucentis Injection dosage varies (ranibizumab)
 

Eligibility Requirements

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Less than 400% of FPL.may qualify. Cost of living in a particular city or state is considered.
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Must reside in the US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Mail
Doctor's Action Complete section, sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months
   

Additional Information

This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease.

Call for most recent medications as the list is subject to change.



Don't qualify for this program?
Visit the DBAs to look for financial assistance based on your diagnosis.

Program 3 of 3. Updated January 30, 2014
Lucentis

Patient Access Network Foundation

This is a copay assistance program.

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


ALT PHONE:
FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website
 

Patient Assistance Applications

PAN Brochure

PAN Eligibility Criteria and Benefit Cap Information

PAN Proof of Expenditure Form

 

Medications

  • Lucentis Injection dosage varies (ranibizumab)
 

Eligibility Requirements

Insurance Status Must have insurance
Those with Part D Eligible? Determined case by case
Income At or below 500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Fax, mail or submit online
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section, sign
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved ; shipped same day.
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

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.