Terms and Conditions for Drug Assistance

By using the LUCENTIS Co-pay Program, the patient acknowledges and confirms that, at the time of usage, (s)he is currently eligible and meets the criteria set forth in the terms and conditions described.

This Co-pay Program is valid ONLY for patients with commercial (private or non-governmental) insurance who are taking the medication for a Food and Drug Administration (FDA)-approved indication. Patients using Medicare, Medicaid, or any other government-funded program to pay for their medications are not eligible. Patients who start utilizing their government coverage during their enrollment period will no longer be eligible for the program.

This Co-pay Program is not health insurance or a benefit plan. Distribution or use of the Co-pay Program does not obligate use or continuing use of any specific product or provider. Patient or guardian is responsible for reporting the receipt of all Co-pay Program 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 Co-pay Program, as may be required.

The Co-pay Program is not valid for medications the patient receives for free or that are eligible to be reimbursed by private insurance plans or other healthcare or pharmaceutical assistance programs (such as Genentech® Access to Care Foundation (GATCF) or any other charitable organization) that reimburse the patient in part or for the entire cost of his/her Genentech medication. Patient, guardian, pharmacist, prescriber, and any other person using the Co-pay Program agree not to seek reimbursement for all or any part of the benefit received by the recipient through the offer.

The Co-pay Program will be accepted by participating pharmacies, physician offices, or hospitals. To qualify for the benefits of this Co-pay Program, the patient may be required to pay out-of-pocket expenses for each treatment. Once enrolled, this Co-pay Program will not honor claims with date of service or medication dispensing that precede program enrollment by more than 120 days. This Co-pay Program 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. Use of this Co-pay Program must be consistent with all relevant health insurance requirements and payer agreements. Participating patients, pharmacies, physician offices, and hospitals are obligated to inform third-party payers about the use of the Co-pay Program as provided for under the applicable insurance or as otherwise required by contract or law. The Co-pay Program may not be sold, purchased, traded, or offered for sale, purchase, or trade. The Co-pay Program is limited to 1 per person during this offer period and is not transferable. Program eligibility period is contingent upon patient's ability to meet and maintain all requirements as set forth by the program. Genentech will periodically verify eligibility and will terminate patients without obligation to pay claims if change to status is detected. This program is not valid where prohibited by law, and shall follow state restrictions in relation to AB-rated generic equivalents where applicable (e.g. MA, CA).

The patient or their guardian must be 18 years or older to receive Co-pay Program assistance. This Co-pay Program is (1) void where prohibited by law; (2) only valid in the United States and Puerto Rico; and (3) only valid 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. Genentech reserves the right to rescind, revoke, or amend the program without notice at any time.

Indication and Important Safety Information

Who is LUCENTIS for?

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), myopic choroidal neovascularization (mCNV), diabetic macular edema (DME), and diabetic retinopathy (DR).

What important safety information should I know about LUCENTIS?

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-eyerelated 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 talk to your doctor and see the LUCENTIS full prescribing information.