Welcome to the LUCENTIS Co-Pay Card Program


The LUCENTIS Co-Pay Card Program can help reduce the out-of-pocket costs* for eligible LUCENTIS patients with commercial insurance, regardless of income.

What does the program cover?

Program
Benefit
  • Up to $5000 per year of the patient's co-pay or co-insurance for LUCENTIS or up to $1500 per year if household income is more than $100,000.
Patient's responsibility
  • The first $5 of their co-pay or co-insurance for LUCENTIS, and any additional out of pocket cost that exceed $1000 per month
Income
Qualification
  • Patients with household income less than $100,000 per year are eligible for full program benefits
  • Patients with household income more than $100,000 per year will receive an annual maximum benefit of $1500 in a 12-month period

*The LUCENTIS Co-Pay Card Program does not cover costs for any other medication, procedure, or diagnostic.

Which patients are eligible?

  • Treated with LUCENTIS for:
    • Neovascular (wet) age-related macular degeneration (wAMD)
    • Macular edema following retinal vein occlusion (RVO)
    • Diabetic macular edema (DME)
IMPORTANT NOTE: Patients must be treated with the dose FDA approved for their indication in order to be eligible.
  • Covered by commercial insurance only
  • Patient not eligible if LUCENTIS prescriptions are paid in part or full by any state or federally funded programs, such as Medicare or Medicaid, Medigap, Medicare Advantage, Managed Medicaid, Veterans Administration (VA), Department of Defense (DoD), or TRICARE
  • Does not currently receive assistance from the Genentech® Access to Care Foundation (GATCF) or other co-pay assistance foundations for LUCENTIS
  • Resides in U.S. Or Puerto Rico

Patients who are ineligible for the LUCENTIS Co-Pay Card Program may be eligible for other types of patient support. Please call LUCENTIS Access Solutions® at (866) 724-9394 for details.

Along with EOBs from a primary payer (and secondary payer, if applicable), you will need the following information when you submit a claim to the LUCENTIS Co-Pay Card Program:

What are the claim submission guidelines?

Format
 
  • EDI 837 for electronic submission
  • HCFA 1500 for paper-based submission, which must be faxed to (855) 320-0457
Payer Number
Required for EDI837
Electronic Submission
  • 05587 (Payer number updated as of September 23, 2013 for electronic processing; formerly 48117)
  • Payer Number not required for HCFA 1500 faxed submissions
Group Number
  • AZ0011
Member ID
Number
  • Found on the patient's enrollment confirmation letter or the patient's co-pay card
NDC Code
  • 50242-080-01 (0.5mg vial of Lucentis)
  • 50242-082-01 (0.3mg vial of Lucentis)
Product J Code
  • J2778

Indication

LUCENTIS® (ranibizumab injection) is indicated for the treatment of patients with:
  • Neovascular (wet) age-related macular degeneration (wAMD)
  • Macular edema following retinal vein occlusion (RVO)
  • Diabetic macular edema (DME)

IMPORTANT SAFETY INFORMATION

LUCENTIS is contraindicated in patients with ocular or periocular infections or hypersensitivity to ranibizumab or any of the excipients in LUCENTIS.

Intravitreal injections, including those with LUCENTIS, have been associated with endophthalmitis, retinal detachment, and iatrogenic traumatic cataract.

Increases in intraocular pressure have been noted both pre-injection and post-injection with LUCENTIS.

Although there was a low rate of arterial thromboembolic events (ATEs) observed in the LUCENTIS clinical trials, there is a potential risk of ATEs following intravitreal use of VEGF inhibitors. ATEs are defined as nonfatal stroke, nonfatal myocardial infarction, or vascular death (including deaths of unknown cause).

In the LUCENTIS Phase III clinical trials, the most common ocular side effects included conjunctival hemorrhage, eye pain, vitreous floaters, and increased intraocular pressure. The most common nonocular side effects included nasopharyngitis, headache, influenza, sinusitis, cough, and nausea.

For additional safety information, please see the LUCENTIS full prescribing information.

CONSOLIDATED TERMS AND CONDITIONS

By using the LUCENTIS Copay Card program, the patient acknowledges and confirms that at the time of usage, they are currently eligible and meet the criteria set forth in the terms and conditions described. This Copay Card is valid ONLY for patients with private insurance or cash-paying patients. It is not valid for patients whose prescription drugs are covered, in whole or in part, under Medicaid, Medicare, a Medicare Part D or Medicare Advantage plan, TRICARE, CHAMPUS, Puerto Rico Government Health Insurance Plan, or any other state or federal healthcare program. Patients who move from commercial to federally funded insurance will no longer be eligible for the program. This card is not health insurance or a benefit plan. Distribution or use of the Copay Card does not obligate use or continuing use of any specific product or provider. Patient or guardian is responsible for reporting the receipt of all Copay benefits or reimbursement received, to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the Copay Card program, as may be required. The Copay Card is not valid for prescriptions that are eligible to be reimbursed by private insurance plans or other healthcare or pharmaceutical assistance programs (e.g.: GATCF) that reimburse you for the entire cost of your prescription drugs. Patient, guardian, pharmacist, prescriber and any other person using the Copay Card agree not to seek reimbursement for all or any part of the benefit received by the recipient through the offer.
The card will be accepted only at participating pharmacies. In order to qualify for this Copay Card, the patient may be required to pay certain out-of-pocket expenses for each treatment. This Copay Card is only available with a valid prescription and cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription. The Copay Card may not be sold, purchased, traded, or offered for sale, purchase or trade. The Copay Card is limited to 1 per person during this offering period and is not transferable. This program expires within 12 months from enrollment. For Massachusetts' residents, this program shall expire on or before July 1, 2015 and is not valid where prohibited by law.
You must be 18 years or older to receive Copay assistance for yourself or a minor. This Copay Card program is: (1) Void if the card is reproduced; (2) Void where prohibited by law; (3) good only in the United States and Puerto Rico; and (4) good only for Genentech products. Healthcare providers may not advertise or otherwise use the program as a means of promoting their services or Genentech's products to patients. Company reserves the right to rescind, revoke, or amend the program without notice at any time.
Click here to see frequently asked questions about the LUCENTIS Co-Pay Card Program.