FOR PHYSICIAN-ADMINISTERED PRODUCTS PATIENT ASSISTANCE PROGRAM (PAP) PATIENT ENROLLMENT FORM INSTRUCTIONS Thank you for your interest in applying to The Safety Net Foundation, a nonprofit organization that helps qualifying patients access Amgen medicines at no cost. ELIGIBILITY GUIDELINES Products available for Replacement: Aranesp (darbepoetin alfa), EPOGEN (Epoetin alfa) for dialysis use only, Neulasta (pegfilgrastim), NEUPOGEN (Filgrastim), Nplate (romiplostim), Prolia (denosumab) injection, Vectibix (panitumumab) injection, and XGEVA (denosumab). Residence: You must reside in the United States, Guam, Puerto Rico or the U.S. Virgin Islands Insurance: You have no insurance for or no access to other coverage or funding for the prescribed Amgen medication Income: Your annual household income meets foundation guidelines as follows: HOW TO APPLY CHECKLIST FOR THE PATIENT: Complete the PATIENT INFORMATION section of the application If you have insurance, you must disclose this information. This includes enrollment in Medicare, Medicaid, or other government programs. Failure to do so may result in a denial. If insured, your diagnosis code is required to obtain coverage information. You can obtain this information from your Physician. Sign the PATIENT CERTIFICATION AND AUTHORIZATION TO DISCLOSE INFORMATION Have your provider fill out their required sections. Fax the completed application to (866) 549-7239. FOR THE PROVIDER: 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. All products requested from The Safety Net Foundation must be administered in the outpatient setting. Complete the PRODUCT INFORMATION Complete the PHYSICIAN AND FACILITY INFORMATION Sign the FACILITY CERTIFICATION Fax the completed application to (866) 549-7239. After product has been administered to the patient request replacement by completing and signing the PRODUCT REPLACEMENT REQUEST FORM*. ONCE A DECISION HAS BEEN MADE, BOTH THE PATIENT AND PROVIDER WILL BE NOTIFIED. MISSING INFORMATION AND/OR INCOMPLETE APPLICATIONS WILL RESULT IN PROCESSING DELAYS. *THIS FORM IS ALSO AVAILABLE FOR DOWNLOAD AT WWW.SAFETYNETFOUNDATION.COM June 2016 Application V12 Page 1 of 4
Patient Name: PATIENT INFORMATION (ALL FIELDS ARE REQUIRED) FOR PHYSICIAN-ADMINISTERED PRODUCTS Last First M.I. Date of Birth: - - Social Security Number: - - Sex: Male Female Patient Mailing Address: You do not need to have a social security number to apply for The Safety Net Foundation Street City State County Zip Code Patient Telephone: - - - - Primary: Home Mobile Work Secondary: Home Mobile Work Patient phone number is required to obtain appropriate consent. Failure to provide accurate information will result in a denial for support. Current Household Income: Weekly Bi-Weekly Monthly Yearly $. Must include all income in the household including wages, Social Security, Social Security disability, unemployment, any pensions, and all other income. Total Number of People Within Household (including patient): Circle One 1 2 3 4 More than 4 print number Must include anyone on your Federal Tax Return*. If you do not file a Federal Tax Return include your spouse, children and parents who live with you. *You do not need to file a tax return to apply for The Safety Net Foundation. No Have you lived in the United States or its territories for six months or longer? No Have you lived in your current state for six months or longer? No Are you a US citizen or resident alien who has lived in the US for five years or longer? You do not need to be a US Citizen to apply for The Safety Net Foundation. No Are you pregnant? No Are you legally blind or otherwise disabled? No Are you a parent or caretaker relative of a child under the age of 18? No Emergency Only Are you enrolled in Medicaid? If yes, the insurance section below must be completed. You must provide your Medicaid insurance information even if you only have Emergency Medicaid. No Have you been denied Medicaid? If yes, a Medicaid denial letter dated within the last 90 days must be submitted with this application. Failure to provide a Medicaid denial letter will result in a denial for support. No Pending Are you enrolled in Medicare? If yes, the insurance section below must be completed. If yes, Medicare Effective Date Medicare Effective Date can be found on the front of your Medicare Card No Pending Are you enrolled in Medicare Part D? If yes, the insurance section below must be completed. No Have you been denied Extra Help (i.e. LIS) from Social Security? If yes, a denial letter must be submitted with this application. No Are you eligible for other federal, state, or local government programs (VA/DOD/IHS)? If yes, the section below must be complete. No Do you have health insurance? If yes, the insurance section below must be completed. Patient s Diagnosis Code(s), i.e. ICD-10: Required if patient has insurance, Obtain this information from your physician before submitting this application to The Safety Net Foundation. Primary Insurance (Medicare, Medicaid, or Health Coverage) Secondary Insurance (Supplemental) Pharmacy Insurance (Medicare Part D or Prescription Coverage) Insurer Name: Plan Name: Phone: Subscriber Name: Subscriber Relationship to Patient: Member ID/Policy Number: Group Number: Insurer Name: Plan Name: Phone: Subscriber Name: Subscriber Relationship to Patient: Member ID/Policy Number: Group Number: Insurer Name: Plan Name: Phone: Subscriber Name: Subscriber Relationship to Patient: Member ID/Policy Number: Group Number: June 2016 Application V12 Page 2 of 4
FOR PHYSICIAN-ADMINISTERED PRODUCTS PATIENT CERTIFICATION AND AUTHORIZATION TO DISCLOSE INFORMATION The 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 1-888-762-6436 and I may revoke it by mailing a revocation to PO Box 18769, Louisville, KY 40261-7821. 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 The Safety Net Foundation for the duration of my enrollment in the Foundation. Any medication I receive through The Safety Net Foundation will not count toward my true-out-of-pocket (TrOOP) expenses in Medicare Part D. The Safety Net Foundation will send a letter to my Medicare Part D plan notifying them of the assistance I am receiving. 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) Failure to provide authentic patient printed name and signature will result in a denial for support. June 2016 Application V12 Page 3 of 4
FOR PHYSICIAN-ADMINISTERED PRODUCTS Patient Last Name: Patient First Name: Patient Date of Birth: Facility Safety Net Customer Number: FACILITY & PRESCRIBING PHYSICIAN INFORMATION - CHOOSE PRODUCT(S) (ALL FIELDS ARE REQUIRED) Aranesp (darbepoetin alfa) for Nephrology EPOGEN (epoetin alfa) for dialysis use only Aranesp (darbepoetin alfa) for Oncology Neulasta (pegfilgrastim) Nplate (romiplostim) NEUPOGEN (Filgrastim) Prolia (denosumab) injection for Bone Health Vectibix (panitumumab) Injection Prolia (denosumab) injection for Oncology XGEVA (denosumab) 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. Free Standing Dialysis Center Specialty Hospital Provider s Office Facility Type Hospital Dialysis Center Community Hospital Pharmacy Infusion Facility Hospital Pharmacy Other Facility Id Pharmacy Director Facility Contact Detail Prescribing Physician NPI: Tax ID: HIN: First Name: Last Name: Phone: - - Fax : - - Facility Name: Facility Contact First and Last Name: Title: Preferred Phone: - - Preferred Fax: - - Mailing Address: Street (PO BOX not accepted) City State Zip First Name: Last Name: Address: Phone: - - Fax : - - National Provider ID (NPI): Provider Transaction Access Number (PTAN): Required if the patient has Medicare. The PTAN is needed to verify insurance benefits. FACILITY CERTIFICATION 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 The Safety Net 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 Safety Net Foundation. I understand that an insurance verification may be required to determine a patient s eligibility for The Safety Net Foundation. I understand that the product received through The Safety Net 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 Safety Net Foundation. I further certify that all product received in connection with The Safety Net Foundation will replace such product; be furnished free of charge for treatment of needy patients who meet The Safety Net Foundation criteria; and, that no part of any charges for Amgen products replaced under The Safety Net Foundation will be claimed as bad debt. I understand that The Safety Net 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 Safety Net Foundation eligibility, I agree to notify The Safety Net Foundation immediately. I agree to release or make available to an authorized The Safety Net Foundation representative the medical and financial records for The Safety Net Foundation patients who have provided consent for such disclosure for the sole purpose of verifying patients eligibility for The Safety Net 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 Safety Net Foundation such records or information. I further certify that I am authorized to act for the institution for which I am signing. Signature of Facility Contact Printed Name of Facility Contact Date Signed 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 Safety Net Foundation. June 2016 Application V12 Page 4 of 4
PRODUCT REPLACEMENT REQUEST FORM INSTRUCTIONS PRODUCT REPLACEMENT REQUEST FORM The 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. Aranesp (darbepoetin alfa) EPOGEN (epoetin alfa) For dialysis use only Neulasta (pegfilgrastim) Replacement Products NEUPOGEN (Filgrastim) Nplate (romiplostim) Prolia (denosumab) injection (PMO & CTIBL use) Vectibix (panitumumab) injection XGEVA (denosumab) REMINDERS Your patient must be enrolled in the Foundation. 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 # of administrations is required. For EPOGEN multi-dose requests, M20 or M10 must be indicated. EPOGEN multi dose vials must accumulate 200,000 units before the product will be shipped regardless of physician s signature. For Aranesp the prescribing physician and their state license number are required. The Safety Net Foundation is available for outpatient use only. The 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) 549-7239. *THIS FORM IS ALSO AVAILABLE FOR DOWNLOAD AT WWW.SAFETYNETFOUNDATION.COM Effective January 2016 Revision REPLACEMENT-REQUEST-v11-12-15 Page 1 of 2
PRODUCT REPLACEMENT REQUEST FORM PRODUCT AVAILABLE ON THIS PRODUCT REPLACEMENT REQUEST FORM (MUST COMPLETE ALL SECTIONS) MULTIPLE PATIENTS AND PRODUCTS MAY BE ENTERED ON A SINGLE FORM IF THE FACILITY CUSTOMER NUMBER AND SHIPPING ADDRESS ARE THE SAME. Aranesp (darbepoetin alfa) EPOGEN (epoetin alfa) For dialysis use only Neulasta (pegfilgrastim) NEUPOGEN (Filgrastim) Nplate (romiplostim) Prolia (denosumab) injection (PMO & CTIBL use) Vectibix (panitumumab) injection XGEVA (denosumab) Facility Name: Facility Customer Number: Facility Contact: Title: Preferred Phone: Preferred Fax: Shipping Address: Patient Name Last, First Patient Date of Birth Street (PO BOX not accepted) City State Zip F or EPO GEN EPO GEN Muli-Dose O nly: Aranesp (Check One) Product Name UOM Kit, V ial, Syring e, Unit Strength Quantity Dispensed Adm inist ra t io n Start Date Adm inist ra t io n End Date TOTAL #A DM IN S REQUIRED FOR EPOGEN AND ARANESP ONLY M20 20,000 1ML M10 20,000 2ML Prescriber Name Prescriber SLN Signer Initials Required 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 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 The Safety Net Foundation and that no part of any charges for Amgen products replaced under The 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 The Safety Net Foundation of any changes I become aware of which could affect patient eligibility with The Safety Net Foundation. I further certify that I am authorized to act for the institution for which I am signing. I understand that The 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 the Safety Net Foundation, the Foundation reserves the right to audit any enrolled facility with a 30-day advance notice. I understand that either the physician OR the facility contact may sign this form. However, in the event that the signature below is not a physician s, The Safety Net Foundation will ship the closest wholesale quantity and credit any remaining balance to my facility s account. AUTHORIZED FACILITY CONTACT OR PHYSICIAN Signature Date Signed Printed First Name Printed Last Name Title Signing Physician State License Number Effective January 2016 Revision REPLACEMENT-REQUEST-v11-12-15 Page 2 of 2