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

Program 1 of 3   Scroll down to see them all.  Updated January 15, 2013 Back | Print Page

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

Genentech Access to Care Foundation (Lucentis)

Provided by:


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

TEL: 800-232-0592


ALT PHONE:
FAX: 888-727-7773
 Program Website

Languages Spoken: English, Spanish, Others By Translation Service

Patient assistance
applications

 

Medications

Lucentis Injection 10mg/mL (ranibizumab)

Eligibility Requirements

APPLICATION

MEDICATION
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
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
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:

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 May 10, 2013 Back | Print Page

This is a copay assistance program.

HealthWell Foundation Copay Program

Provided by:


HealthWell Foundation
P.O Box 4133
Gaithersburg, MD 20897-7811

TEL: 800-675-8416


ALT PHONE:
FAX: 800-282-7692
 Program Website

Languages Spoken: English, Others By Translation Service

Patient assistance
applications

 

Medications

Lucentis Injection  (ranibizumab)

Eligibility Requirements

APPLICATION

MEDICATION
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
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 proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
Amount/Supply Not applicable
Sent To
Delivery Time
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 February 12, 2013 Back | Print Page

This is a copay assistance program.

Patient Access Network Foundation

Provided by:


Patient Access Network Foundation
PO Box 221858
Charlotte, NC 28222

TEL: 866-316-7263


ALT PHONE:
FAX: 866-316-7261
 Program Website

Languages Spoken: English, Spanish, Others By Translation Service

Patient assistance
applications


 

Medications

Lucentis Injection  (ranibizumab)

Eligibility Requirements

APPLICATION

MEDICATION
Insurance Status Must have insurance
Those with Part D Eligible? Yes
Income At or below 500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Must reside and receive treatment in US
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, attach proof of income
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
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.



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