PATIENT INSTRUCTIONS PATIENT INFORMATION SECTION. Last name First name Middle initial

Transcription

1 Amgen Safety Net Foundation is a nonprofit organization that helps qualifying patients access Amgen medicines at no cost. To apply for support you must: 3 Be taking one of these Amgen medicines: Aranesp (darbepoetin alfa) EPOGEN (Epoetin alfa) for dialysis use only Kyprolis (carfilzomib) Neulasta (pegfilgrastim) NEUPOGEN (Filgrastim) 3 Live in the United States, American Samoa, Guam, Puerto Rico, or the U.S. Virgin Islands 3 Have no insurance for or no access to other coverage or funding for the prescribed Amgen medication 3 Have an income at or below these amounts: More than four? Add $20,900 for each extra person 3 Complete the PATIENT INFORMATION SECTION (pages 1-2) of the application All insurance must be reported, including Medicare, Medicaid, or other government programs If you have insurance, you will need a diagnosis code. Ask your physician s office to give this to you 3 Sign the PATIENT CERTIFICATION AND AUTHORIZATION TO DISCLOSE INFORMATION SECTION (page 3) of the application 3 Have provider fill out the FACILITY AND PRESCRIBING PHYSICIAN INFORMATION SECTION (page 4) 3 Fax the completed application to (866) Your information PATIENT INSTRUCTIONS If you have this many people in your household PATIENT INFORMATION SECTION Nplate (romiplostim) Parsabiv (etelcalcetide) Prolia (denosumab) injection Vectibix (panitumumab) injection XGEVA (denosumab) your household income must be at or below this much each year $60,300 $81,200 $102,100 $123,000 name name Middle initial Date of birth / / Social Security Number - - mm dd yyyy (If you do not have a Social Security Number you may skip this question) Address City State County Zip Code Main telephone ( ) - Home Mobile Work Secondary telephone ( ) - Home Mobile Work (Please include a working phone number. We may need to call you to complete the application process) 2. Where you live Yes No Have you lived in the United States, American Samoa, Guam, Puerto Rico, or the U.S. Virgin Islands for six months or longer? Yes No Have you lived in your current state for six months or longer? Yes No Are you a U.S. citizen or resident alien who has lived in the U.S. for five years or longer? (You do not need to be a U.S. citizen to apply) Effective February 2017 Physician Administered Application V15 Page 1 of 4

2 3. Your income My household makes $. Every: week other week month year (Your household income is all income made by the people in your household. This includes wages, Social Security, Social Security disability, unemployment, any pensions, and any other income. You may be asked to provide proof of all income you include.) How many people live in your household? (include yourself) More than 4, print # Medicare Medicaid Other 4. Your eligibility for government programs 5. Your insurance Yes No Pending Do you have Medicare? Yes No Pending Do you have Medicare Part D? (If you filed a U.S. Tax Return, your household is everyone you put on that form. You do not need to file a tax return to apply. If you do not file a Tax Return, include people who live with you. For example you, your children, your spouse, and your parents) (If you said yes, write your Medicare Effective Date here: / /. It is on the front of your Medicare Card) Yes No Do you have Medicaid? If yes, is it Emergency Medicaid? Yes No (You MUST provide your Medicaid insurance information even if you only have Emergency Medicaid) Yes No Have you been (If you said yes, you MUST include your Medicaid denial letter. denied Medicaid? The letter must be from the last 90 days) Yes No Are you pregnant? Yes No Are you legally blind or otherwise disabled? Yes No Are you a parent or caretaker relative of a child under the age of 18? Yes No Are you eligible for any federal, state, or local government programs? (Including Veterans Affairs, Dept. of Defense, or Indian Health Services) Select the statement that applies I do not have insurance I have insurance but the Amgen product is not covered I have insurance with a high out-of-pocket cost to your insurance status: (If you do not have insurance, you may skip this section. If you have health insurance, Medicare, or Medicaid, you need to fill in the blanks below) STOP! You MUST include a diagnosis code Diagnosis code or codes:, (ICD-10 code. Your physician can provide this to you. You may have more than one code) Your primary insurance (Medicare, Medicaid, or Health Coverage) Insurer name Plan name Plan phone # ( ) - Subscriber name Subscriber relationship to patient Member ID/policy # Group # Your secondary insurance (Supplemental) Insurer name Plan name Plan phone # ( ) - Subscriber name Subscriber relationship to patient Member ID/policy # Group # Your pharmacy insurance (Medicare Part D or Prescription Coverage) Insurer name Plan name Plan phone # ( ) - Subscriber name Subscriber relationship to patient Member ID/policy # Group # STOP! Check every section of this form. Have you filled in every blank? If you did, read and sign the next page. Effective February 2017 Physician Administered Application V15 Page 2 of 4

3 PATIENT CERTIFICATION AND AUTHORIZATION TO DISCLOSE INFORMATION SECTION Amgen Safety Net Foundation the Foundation is a nonprofit patient assistance program supported by Amgen that provides qualifying patients with Amgen products at no cost. Authorization to Disclose Information I authorize the Foundation, Amgen, their agents, and third-party contractors or their service providers authorized to administer the Foundation to: use the information that I provided on the Foundation application form to determine my eligibility for and assist with my continued participation in the Foundation. use my Social Security number to access my credit information and information derived from public and other sources to estimate my income in conjunction with the eligibility determination process. contact me to seek feedback on the Foundation s services. For these purposes, I also authorize my physician, healthcare professionals, health plan(s), care givers, and family members to disclose to the Foundation, Amgen, their agents, and third-party contractors or their service providers authorized to administer the Foundation information about my medical condition, treatment, and health insurance coverage. I understand that: I may refuse to sign this form, but if I refuse to sign or revoke my authorization, I will not be able to receive assistance from the Foundation. my healthcare provider or insurers will not condition my medical treatment or insurance benefits on my agreement to sign this form. once I provide the information as described above to the Foundation, Amgen, the agents, and third-party contractors or their service providers working on their behalf pursuant to this authorization, federal privacy laws may not prevent further disclosure of this information. I may receive a copy of this form at any time by contacting the Foundation at and I may revoke it by mailing a revocation to PO Box 18769, Louisville, KY a revocation must be in writing and is not effective to the extent that action has already been taken based on this authorization. this authorization will expire one (1) year after the date it is signed below or one (1) year after the last date I receive product from the Foundation, whichever is later. Patient Certification I certify that: the information I provided on the Foundation application form is complete and accurate. I will not request reimbursement from any insurance carrier or government health benefit program for Amgen products that I receive from the Foundation. I will notify the Foundation within thirty (30) days if my financial status or health insurance coverage changes. If I decide to enroll in a Medicare Part D plan, I will inform the Foundation at the number below prior to enrolling. If I receive notice that I have auto-enrolled in a Medicare Part D plan, I will immediately inform the Foundation. I will not sell, trade, or distribute Amgen products given to me by the Foundation. I understand that completing the Foundation application form is not a guarantee of eligibility for the Foundation. I also understand that the Foundation may change or discontinue the program at any time without notice, except that if I am enrolled in a Medicare Part D plan, my benefits will continue until the end of the calendar year. I understand that if I am currently enrolled in a Medicare part D plan, I cannot utilize my Part D plan benefits for products received through Amgen Safety Net Foundation for the duration of my enrollment in the Foundation. Any medication I receive through Amgen Safety Net Foundation will not count toward my true-out-of-pocket (TrOOP) expenses in Medicare Part D. Amgen Safety Net Foundation will send a letter to my Medicare Part D plan notifying them of the assistance I am receiving. Amgen Safety Net Foundation does not charge a fee for participation. If you use a third party who charges a fee for help with your enrollment or refills of your medicine(s), this money is not paid to Amgen Safety Net Foundation. Printed Name of Patient or Personal Representative Signature of Patient or Personal Representative Dated Description of Personal Representative s Authority to Sign for Patient (Attach documents which show authority) Effective February 2017 Physician Administered Application V15 Page 3 of 4

4 Patient Products Facility Pharmacy Director Facility Contact Detail Prescribing Physician FACILITY AND PRESCRIBING PHYSICIAN INFORMATION SECTION (Your provider must fill this out) Patient name Date of birth / / Aranesp (darbepoetin alfa) For Nephrology For Oncology EPOGEN (Epoetin alfa) for dialysis use only Is the patient on dialysis? Yes No Kyprolis (carfilzomib) Free-Standing Dialysis Center Hospital Dialysis Center Parsabiv (etelcalcetide) Providers must administer eligible Foundation product(s) from their existing commercial stock to enrolled Foundation patients and then request replacement for these product(s) from the Foundation using the Product Replacement Request Form. Facility Safety Net Customer Number (Required to complete enrollment. To obtain, call ) National Provider ID (NPI) Tax ID HIN Pharmacy Director Name Phone ( ) - Fax ( ) - Facility Name Facility Contact Name Prescribing Physician Name Phone ( ) - Fax ( ) - Street Address National Provider ID (NPI) Infusion Facility Specialty Hospital Neulasta (pegfilgrastim) NEUPOGEN (Filgrastim) Nplate (romiplostim) Community Hospital Hospital Pharmacy Phone ( ) - Fax ( ) - Street Address Provider s Office Pharmacy Street (PO BOX not accepted) City State Provider Transaction Access Number (PTAN) (Required if the patient has Medicare) Prolia (denosumab) injection For Bone Health For Oncology Vectibix (panitumumab) Injection XGEVA (denosumab) Street (PO BOX not accepted) City State ZIP Yes No Is this application and associated forms being completed by a third-party (TPA), an agent, or a service provider authorized to act on behalf of the facility? (Failure to disclose the use of a Third Party Administrator could result in withdrawal from participation in the foundation.) FACILITY CERTIFICATION SECTION By submitting this application, I agree to the following: I will provide Amgen products for patients in a medically appropriate manner based on a valid physician s order or prescription. I understand that Amgen Safety Net Foundation, the Foundation reserves the right to change or terminate this program at any time, or to refuse to distribute Amgen products under this program to any patient or facility. I understand that product is provided on a replacement basis. Participating providers are required to stock the product and apply for replacement product through the Foundation. I understand that an insurance verification may be required to determine a patient s eligibility for the Foundation. I understand that the product received through the Foundation is for medically needy patients living in the United States and its territories. I certify that I will not charge or cause any other party to charge any third party or patient for Amgen products for which replacement is sought under the Foundation. I further certify that all product received in connection with the Foundation will replace such product; be furnished free of charge for treatment of needy patients who meet the Foundation criteria; and, that no part of any charges for Amgen products replaced under the Foundation will be claimed as bad debt. I understand that the Foundation is available for outpatient use only. I certify that no replacement will be requested for product administered in the hospital inpatient setting. I represent that the information contained in all patient applications under my facility, including the patient application form will be complete and accurate to the best of my knowledge. This representation does not require my independent investigation of the information. If I become aware of any changes in the patient s circumstances that affect the Foundation eligibility, I agree to notify the Foundation immediately. I agree to release or make available to an authorized Foundation representative the medical and financial records for the Foundation patients who have provided consent for such disclosure for the sole purpose of verifying patients eligibility for the Foundation. I agree that I will not provide patient information without obtaining appropriate consent from each patient prior to releasing or making available to the Foundation such records or information. I further certify that I am authorized to act for the institution for which I am signing. Title Other ZIP Signature of Facility Contact Printed Name of Facility Contact Date Signed Effective February 2017 Physician Administered Application V15 Page 4 of 4

5 PRODUCT REPLACEMENT REQUEST FORM Amgen Safety Net Foundation offers replacement product for physician-administered medications. Under this model, providers administer Amgen product from their existing commercial stock to qualifying Foundation patients and then order replacement for this product from the Foundation. These products must be administered in an outpatient setting to be eligible for replacement. Use this form for the following products: Aranesp (darbepoetin alfa) Kyprolis (carfilzomib) EPOGEN (Epoetin alfa) Neulasta (pegfilgrastim) for dialysis use only NEUPOGEN (Filgrastim) Important reminders Your patient must be enrolled in the Foundation. Nplate (romiplostim) Parsabiv (etelcalcetide) Prolia (denosumab) injection (PMO & CTIBL use) Vectibix (panitumumab) injection XGEVA (denosumab) Request for dates of administration in the future cannot be processed. Replacement product may only be requested for dates of administration up to six months prior to the patient s enrollment start date. For EPOGEN the total number of administrations is required. For EPOGEN multi-dose requests, M20 or M10 must be indicated. Multi-dose vials must accumulate 200,000 units before the product will be shipped. For Aranesp the prescribing physician and their state license number are required. Amgen Safety Net Foundation is available for outpatient use only. Amgen Safety Net Foundation does not provide support for product administered in the hospital inpatient setting. All information on this form is required. Failure to complete all information will result in shipment delays. Fax the completed Product Replacement Request Form* to (866) *This form is also available for download at Effective February 2017 Replacement Request Form V15 Page 1 of 2

6 This form can be used for the following products. Multiple patients and products may be entered on a single form if the facility customer numbers and shipping address are the same. Aranesp (darbepoetin alfa) Kyprolis (carfilzomib) NEUPOGEN (Filgrastim) EPOGEN (Epoetin alfa) Neulasta (pegfilgrastim) Nplate (romiplostim) for dialysis use only Facility Information Parsabiv (etelcalcetide) Prolia (denosumab) injection PRODUCT REPLACEMENT REQUEST FORM Vectibix (panitumumab) Injection XGEVA (denosumab) Facility Name ASNF Facility Customer Number (Required to verify facility. To obtain, call ) Facility Contact Name Title Phone ( ) - Fax ( ) - Shipping Address HIN DEA Patient Information Street (PO BOX not accepted) City State ZIP Fill out these columns for Aranesp (darbepoetin alfa) and EPOGEN (Epoetin alfa) only Patient name Patient UOM Product Name (, ) Date of Birth (Kit, vial, Strength Quantity Administration Administration EPOGEN (Epoetin alfa) only Aranesp (darbepoetin alfa) Dispensed Start Date End Date Total # Multi-dose only check one syringe, unit) Prescriber Prescriber of Admins M20 20,000 1ML M10 20,000 2ML Name SLN Physician Required To Initial Each Line I certify that the Amgen product reported on this form, for which I am requesting free replacement, was furnished free of charge to the designated Amgen Safety Net Foundation patient. I further certify that I will not charge or cause any other party to charge any third party or patient for Amgen products for which replacement is sought under Amgen Safety Net Foundation and that no part of any charges for Amgen products replaced under Amgen Safety Net Foundation will be claimed as bad debt. I represent that the information provided in this form is complete and accurate to the best of my knowledge and agree to notify Amgen Safety Net Foundation of any changes I become aware of which could affect patient eligibility with Amgen Safety Net Foundation. I further certify that I am authorized to act for the institution for which I am signing. I understand that Amgen Safety Net Foundation is available for outpatient use only. I certify that no replacement was requested for product administered in the hospital inpatient setting. I authorize this replacement order/prescription to be shipped to my office for in-facility use. I understand in order to ensure that appropriate patients are helped by Amgen Safety Net Foundation, the Foundation reserves the right to audit any enrolled facility with a 30-day advance notice. Physician Signature Date Signed Printed Name Printed Name Signing Physician State License Number *This form is also available for download at Effective February 2017 Replacement Request Form V15 Page 2 of 2