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ALL SECTIONS OF THIS FORM MUST BE COMPLETEDApplication for individual reimbursement of voretigene neparvovec (Luxury) For MMP Use Only Case Reference Date ReceivedDate of Application:Part 1: Patient
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How to fill out voretigene neparvovec luxturna application

01
Obtain the voretigene neparvovec Luxturna application form from the prescribing healthcare provider or the pharmaceutical company.
02
Fill out all required personal information, including name, address, date of birth, and contact information.
03
Provide details about the medical condition for which voretigene neparvovec Luxturna is being prescribed.
04
Include information about insurance coverage and any financial assistance programs being utilized.
05
Submit the completed application form along with any supporting documents to the appropriate party for processing.

Who needs voretigene neparvovec luxturna application?

01
Individuals with a confirmed diagnosis of an inherited retinal disease caused by mutations in both copies of the RPE65 gene may need voretigene neparvovec Luxturna application.
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Voretigene neparvovec Luxturna application is a form used to request approval for the Luxturna gene therapy treatment.
Patients with a confirmed diagnosis of an inherited retinal disease caused by mutations in both copies of the RPE65 gene are required to file the Luxturna application.
The Luxturna application can be completed by the patient's healthcare provider or by the patient themselves with assistance from their healthcare provider.
The purpose of the Luxturna application is to apply for approval to receive the Luxturna gene therapy treatment for an inherited retinal disease caused by mutations in both copies of the RPE65 gene.
The Luxturna application must include the patient's medical history, genetic test results confirming mutations in both copies of the RPE65 gene, and information about the patient's eye health.
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