Find the enrollment forms you'll need to help patients access LUCENTIS after it's been prescribed, including for coverage, reimbursement and financial assistance services. There are also tips for composing a letter of medical necessity and appeal letter.
To learn more about the resources available to help your practice, including information on benefits investigations and prior authorizations, go to Helpful Resources for Your Practice.
Genentech Ophthalmology Access Solutions can help your patients better understand their coverage, find financial assistance options, learn how to get LUCENTIS and know which specialty pharmacy their health insurance plan requires.
This form is used to collect the patient’s health insurance and treatment information for enrollment in Genentech Ophthalmology Access Solutions.
This form is signed and dated by your patient, giving written permission for Genentech Ophthalmology Access Solutions to discuss their health information with you and the patient's health insurance plan.
A version of the Patient Consent Form for your Spanish-speaking patients.
The Genentech Patient Foundation provides free LUCENTIS to people who don’t have insurance coverage or who have financial concerns and meet eligibility criteria.
The following forms are needed for applying for assistance from the Genentech Patient Foundation. Learn more about the Genentech Patient Foundation and other resources programs.
Includes patient, insurance and prescription information. Page two must be completed and submitted by the prescriber.
This form is signed and dated by your patient, giving written permission for Genentech Ophthalmology Access Solutions to discuss their health information with you and the patient's health insurance plan.
A version of the Patient Consent Form for your Spanish-speaking patients.
This guide provides tips to help you draft a letter of medical necessity. A sample letter is also included for your reference.
This guide provides tips to help you draft an appeal letter. A sample letter is also included for your reference.
Use the links below to find additional information to enclose in your letter of medical necessity or appeal letter:
LUCENTIS [package insert]. South San Francisco, CA: Genentech, Inc; 2018.
LUCENTIS [package insert]. South San Francisco, CA: Genentech, Inc; 2018.
Rosenfeld PJ, et al; MARINA Study Group. N Engl J Med. 2006;355:1419-1431.
Rosenfeld PJ, et al; MARINA Study Group. N Engl J Med. 2006;355:1419-1431.
Brown DM, et al; ANCHOR Study Group. Ophthalmology. 2009;116:57-65.
Brown DM, et al; ANCHOR Study Group. Ophthalmology. 2009;116:57-65.
Data on file. South San Francisco, CA: Genentech, Inc.
Data on file. South San Francisco, CA: Genentech, Inc.
Busbee BG, et al; HARBOR Study Group. Ophthalmology. 2013;120:1046-1056.
Busbee BG, et al; HARBOR Study Group. Ophthalmology. 2013;120:1046-1056.
Ho AC, et al; HARBOR Study Group. Ophthalmology. 2014;121:2181-2192.
Ho AC, et al; HARBOR Study Group. Ophthalmology. 2014;121:2181-2192.
Sarraf D, et al. Ophthalmology. 2016;123(10):2213-2224.
Sarraf D, et al. Ophthalmology. 2016;123(10):2213-2224.
Heier JS, et al; VIEW 1 and VIEW 2 Study Groups. Ophthalmology. 2012;119(12):2537-2548.
Heier JS, et al; VIEW 1 and VIEW 2 Study Groups. Ophthalmology. 2012;119(12):2537-2548.
Eylea [package insert]. Tarrytown, NY: Regeneron Pharmaceuticals, Inc; 2019.
Eylea [package insert]. Tarrytown, NY: Regeneron Pharmaceuticals, Inc; 2019.
Schmidt-Erfurth U, et al. Ophthalmology. 2014;121:193-201.
Schmidt-Erfurth U, et al. Ophthalmology. 2014;121:193-201.
The information contained in this section of the site is intended for U.S. healthcare professionals only. Click "OK" if you are a healthcare professional.
The link you have selected will take you away from this site to one that is not owned or controlled by Genentech, Inc. Genentech, Inc. makes no representation as to the accuracy of the information contained on sites we do not own or control. Genentech does not recommend and does not endorse the content on any third-party websites. Your use of third-party websites is at your own risk and subject to the terms and conditions of use for such sites.