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Lucentis

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Genentech Access to Care Foundation (Lucentis)

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

Provided by: Genentech, Inc.

PO Box 2807
South San Francisco, CA 94083-2807

TEL: 800-232-0592


FAX: 888-727-7773
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

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 Patient Financial Attestation Form: Lucentis: Contact program

Genentech Confirmation of Infusion or Injection Form: Lucentis

Genentech Fax Cover Sheet: Lucentis

 

Medications

  • Lucentis injection (ranibizumab)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage or been denied coverage
Those with Part D Eligible? Determined case by case
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/Doctor's office starts process by filling out enrollment/statement of medical necessity forms
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
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.


Updated September 17, 2015


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

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Patient Access Network Foundation (PAN)

This is a copay assistance program.

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

PAN Proof of Expenditure Form

PAN Eligibility Criteria and Benefit Cap Information

PAN Brochure

 

Medications

  • Lucentis (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/diagnosis
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 and 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.


Updated July 10, 2015


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 3.
 

Lucentis

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Good Days Program

This is a copay assistance program.

Provided by: Good Days from CDF

6900 dallas Parkway
Ste. 200
Plano, TX 75024

TEL: 877-968-7233


FAX: 214-570-3621
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Good Days Program Patient Enrollment Application 2016 (pages: 3-5)

Good Days Program Enrollment Information Pages for 2016 (pages: 1, 2 & 6)

 

Medications

  • Lucentis (ranibizumab)
 

Eligibility Requirements   

Insurance Status Not specified
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Not specified
   

Application

Obtaining Call, download or apply online
Receiving Faxed, mailed or downloaded from website
Returning Fax, mail or submit online
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient and/or Doctor are notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Must re-enroll at end of calendar year
   

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.
Updated November 24, 2015