Forms and Documents

Here you can download the form you need to enroll in LUCENTIS Access Solutions and other important information. Please remember, your doctor also needs to fill out a form to enroll you.

Start Enrollment With the PAN Form

To get started, fill out a form called the PAN. You can find this form below.

SMN

Your doctor also has to fill out a form called the SMN. Once we have both these forms, we can begin working with you and your doctor’s office. You do not have to fill out any information on this form.

Treatment Cost Discussion Guide

This information packet includes:

  • Questions to consider asking someone at your doctor's office after you have been prescribed a Genentech medicine
  • Information on how to enroll in LUCENTIS Access Solutions
  • A copy of the PAN form

PAN=Patient Authorization and Notice of Request for Transmission of Health Information to Genentech Access Solutions and Genentech® Access to Care Foundation.

SMN=Statement of Medical Necessity.

Important Safety Information & Indication

What it Treats

LUCENTIS® (ranibizumab injection) is a prescription medicine for the treatment of patients with:

  • wet age-related macular degeneration (wAMD),
  • macular edema following retinal vein occlusion (RVO)
  • diabetic macular edema (DME)
  • diabetic retinopathy (DR) with DME
  • myopic choroidal neovascularization (mCNV)

Important Safety Information

You should not use LUCENTIS if you have an infection in or around the eye or are allergic to LUCENTIS or any of its ingredients. LUCENTIS is a prescription medication given by injection into the eye, and it has side effects. Some LUCENTIS patients have had detached retinas and serious eye infections. If your eye becomes red, sensitive to light, or painful, or if you have a change in vision, call or visit your eye doctor immediately. Some LUCENTIS patients have had increased eye pressure before and within 1 hour of an injection. Uncommonly, LUCENTIS patients have had serious, sometimes fatal, problems related to blood clots, such as heart attacks or strokes. Fatal events were seen more often in patients with DME and DR with LUCENTIS compared with patients who did not receive Lucentis. Although there were only few fatal events, which included causes of death typical of patients with advanced diabetic complications, these events may be caused by Lucentis.

Some LUCENTIS patients have serious side effects related to the injection. These include serious infections inside the eye, detached retinas, and cataracts. The most common eye-related side effects are increased redness in the white of the eye, eye pain, small specks in vision, and increased eye pressure. The most common non–eye-related side effects are nose and throat infections, anemia, nausea and cough. Ask your doctor if you have questions or want more information.

You may report side effects to the FDA at (800) FDA-1088 or www.fda.gov/medwatch. You may also report side effects to Genentech at (888) 835-2555.

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