Prescriber’s last name*: First name*:

Practice name: Specialty:

Street*: Suite: City*: State*: ZIP*:

Phone: ( ) Fax: ( ) Prescriber tax ID #: Prescriber NPI #‡:

DEA #: Group NPI #: State license #: PTAN§:

Reimbursement/clinical contact name: Phone: ( ) Fax: ( )

STATEMENT OF MEDICAL NECESSITY (SMN)

Benefits Investigation/Prior Authorization Refer Patient to Co-pay Assistance

Appeals Support GATCF† Patient Assistance

Last name*: First name*: Birth date*: / / Gender: Male Female

Street: City: State*: ZIP:

Home phone: ( ) Cell phone: ( ) OK to contact patient? Yes No Pt. preferred language (if other than English):

Alternate contact name: Relationship: Alternate phone: ( )

PHYSICIAN CERTIFICATION: By signing below, I certify: (a) the above therapy is medically necessary, (b) I received the authorization to release the information above and other protected health information (as defined by the Health Insurance Portability and Accountability Act of 1996 [HIPAA]) to Genentech, Inc., Genentech Access Solutions, the contracted dispensing pharmacy, or other contractors for the purpose of requesting reimbursement support, assisting in initiating or continuing therapy and/or the evaluation of the patient’s eligibility for GATCF, as a break in treatment would negatively impact the patient’s therapeutic outcome and (c) I will not attempt to seek reimbursement for free product provided to the patient. I request Genentech Access Solutions convey to the pharmacy chosen by the above-named patient the prescription described herein. I agree to comply with the Genentech, Inc. program guidelines and understand that GATCF, at its sole discretion, reserves the right to modify or discontinue the program at any time and to verify the accuracy of the information submitted. I further understand that Genentech will provide vial replacement in a configuration that will create the least wastage. If applying for GATCF, I certify that (a) this patient has no medical insurance coverage or otherwise meets the financial criteria for the prescribed therapy, and is not eligible for other product financial support programs, and (b) the therapy identified above will not be used in a clinical trial. Note: Prescribers in all states must follow applicable law for a valid prescription and who is considered an authorized prescriber. For prescribers in states with official prescription form requirements, such as New York, please submit prescriptions on an official state prescription blank along with this form. Unapproved Use Warning: Please read the FDA-approved label for Genentech products before prescribing. If the indication for which you are prescribing a Genentech product is not listed in the FDA-approved label, you are prescribing the medication for an “unapproved” use, meaning that the FDA has not approved the efficacy, dosage amount or safety of this medication when used for such a use. Nevertheless, GATCF will consider providing the medication for your patient with this admonition, based upon your medical order, within program requirements.

*Required field. †Genentech® Access to Care Foundation. ‡National Provider Identifier. §Provider Transaction Access Number.

Specialty pharmacy needed for dispensing: Yes No (MD office will supply) Preferred specialty pharmacy:

Ship to address (if different from office shown below):

Required field (*) ACS/062315/0106(4) 1/18

PLEASE SUBMIT SMN AND PAN FORMS ONLY.

Sign and date here* Prescriber’s Signature*: Date*: / / (Original or stamped signature required.)

Phone: (866) 724-9394 Fax: (866) 724-9412 Genentech-Access.com/LUCENTIS

LUCENTIS® (ranibizumab injection):

DISPENSE: vial(s) or prefilled syringes 0.05 mL of a 10-mg/mL solution

SIG: Inject 0.5 mg (0.05 mL) intravitreally monthly

SIG: Inject 0.5 mg (0.05 mL) intravitreally monthly x4 months then quarterly

SIG: Inject 0.5 mg (0.05 mL) intravitreally monthly x3 months then as needed (PRN)

SIG: Refill: times

DISPENSE: vial(s) or prefilled syringes 0.05 mL of a 6-mg/mL solution

SIG: Inject 0.3 mg (0.05 mL) intravitreally monthly

SIG: Refill: times

Diagnosis/Treatment

Prescription

Prescriber

Patient

SERVICES REQUESTED* (check only those that apply)

PRIMARY INSURANCE

No insurance

Primary insurance name:

Phone: ( ) Subscriber name:

Subscriber ID #: Policy/group #:

SECONDARY INSURANCE

No secondary insurance

Secondary insurance name:

Phone: ( ) Subscriber name:

Subscriber ID #: Policy/group #:

InsurancePlease do not submit a photocopy of the patient’s insurance information.

Please provide the appropriate diagnosis code(s) to the highest level of specificity. For ICD-10 coding information, please visit Genentech-Access.com/LUCENTIS. Anticipated date of treatment: / /

Primary diagnosis code*: Secondary diagnosis code:

Tertiary diagnosis code:

T:8.5”T:11”

B:8.75”B:11.25”

Genentech-Access.com/LUCENTISPhone: (866) 724-9394 Fax: (866) 724-9412

LUCENTIS®, its logo, My Patient Solutions® and the Access Solutions logo are registered trademarks of Genentech, Inc.

©2018 Genentech USA, Inc. So. San Francisco, CA All rights reserved. ACS/062315/0106(4) 01/18

STATEMENT OF MEDICAL NECESSITY (SMN)Please write legibly and complete all required fields (*) to prevent delays. Complete this form online via My Patient Solutions®, our online patient management tool. Visit Genentech-Access.com/LUCENTIS to register for My Patient Solutions.

SERVICES REQUESTED

Check the appropriate services requested on behalf of the patient. LUCENTIS Access Solutions and/or GATCFcannot perform services without your specific request

DIAGNOSIS/TREATMENT

Complete the diagnosis coding to the highest level of specificity

For ICD-10 coding information, please visit Genentech-Access.com/LUCENTIS

PRESCRIPTION

Please ensure you complete all areas of the prescription portion clearly and completely

LUCENTIS is available in vials of a 6-mg/mL or 10-mg/mL solution or prefilled syringes of a 6-mg/mLor 10-mg/mL solution

LUCENTIS should be refrigerated at 2-8º C (36-46º F). Please indicate where to send shipments (if different from theprescriber address) to ensure the drug will be stored appropriately

PRESCRIBER

Requests for appeals support and GATCF patient assistance cannot be processed without an original or stamped signature

ATTACH TO COMPLETED SMN

Attach a signed and dated Patient Authorization and Notice of Request for Transmission of Health Information toGenentech Access Solutions and Genentech® Access to Care Foundation (PAN) form. LUCENTIS Access Solutionsand/or GATCF cannot work with the insurance plan on your patient’s behalf without a signed and dated PAN form

ONLY THE INFORMATION REQUESTED ON THESE FORMS IS REQUIRED. PROVIDING ADDITIONAL DOCUMENTS OR INFORMATION WILL DELAY PROCESSING.

T:8.5”T:11”

B:8.75”B:11.25”