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PATIENT INSTRUCTIONSAmgen Safety Net Foundation is a nonprofitpatient assistance program that helps qualifyingpatients access Amgen medicines at no cost.Are you eligible?Apply for support if you meet the following requirements: You have lived in the United States, American Samoa,Guam, Puerto Rico, or the U.S. Virgin Islands for sixmonths or longer. You have a household income at or below: 64,400. for a household of 1 person 87,100. for a household of 2 peopleAdd 22,700 for each extra person. You may be asked to provideproof of income in order to determine eligibility. Your assets are valued at less than 29,250 (if you aremarried, living with spouse) or 14,960 (if you are notmarried or living with spouse) Assets include combinedsavings, investments and real estate combined, but do notinclude home, vehicles, personal possessions, life insurance,burial plots, irrevocable burial contracts or back payments fromSocial Security or SSI. You are uninsured or your insurance plan excludes theAmgen medicine or its generic/biosimilar.C ertain Medicare Part D patients with coverage for theAmgen medicine who cannot afford their out of pocketcosts may be eligible. It is required that you are able todemonstrate: Y our inability to afford the medicine Your ineligibility for Medicaid or Medicare’s low-incomesubsidy (Extra Help)Prior to applying If you are insured, contact your healthcareplan to understand your medicinecoverage. If you have been denied coverage for theAmgen medicine (0% coverage) you mustexhaust the maximum coverage appealsallowed by your healthcare plan, andsubmit this final denied determinationletter with your application. If you have Medicare Part D, submit yourfinal determination letter from yourinsurance stating that an active PriorAuthorization (PA) is on file with yourhealthcare plan. If you are a low-income patient, applyto your local Medicaid office for healthcareinsurance and where applicable, Medicare’slow-income subsidy (Extra Help). If denied,submit this supporting documentation.How to applySTEP 1Complete all sections of thePATIENT APPLICATION (pages 1–3).Applications missing required informationcannot be processed. Both pages 2 and3 must each be personally signed (noelectronic signatures) and dated to completethe application.STEP 2Have your physician fill out thePRESCRIPTION (page 4).STEP 3 Have your prescribing physician faxthe completed application and prescriptionto: 1-833-959-1409. Y ou have satisfied all payer guidelines and PriorAuthorization (PA) requirements prior to applying forassistance Y ou do not have any other financial support optionsQuestions?What happensafter I apply?You and your physician will both be notifiedonce a decision is made. If you are approved,you will be contacted by a Patient AssistanceCounselor to obtain your consent to schedulea shipment of your Amgen medicine.Contact us at 1-800-932-3060, Monday through Friday 8amto 8pm Eastern Time.v6-Mar-2021 PO Box 19148, Lenexa, KS 66285 Phone: 1-800-932-3060 Fax: 1-833-959-1409 amgensafetynetfoundation.com
PATIENT APPLICATIONPATIENT INFORMATION Please PRINT all information on this form legibly1. Prescribed medicine Aimovig (erenumab-aooe)2. Your info Last nameMaleFemaleDate of birthPage 1 of 4First nameMM/DD/Middle initial-Social Security NumberYYYYAddress-CityStatePreferred telephone--HomeMobileWork Best time to callAlternate telephone--HomeMobileWork Preferred rBy providing your phone number and email, you allow us to contact you to complete the application process.3. Where you liveAre you a:U.S. citizenResident alienNeitherYou have lived in the U.S. or its territories (American Samoa, Guam, Puerto Rico, or U.S. Virgin Islands):You have lived in your current state:4. Your incomeGreater than 6 monthsGreater than 6 monthsLess than 6 monthsLess than 6 months y household makes Mmonthlyannually prior to taxes being withheld. Include allindividuals in your household. Include wages, Social Security, Social Security disability, unemployment, pensions,and any other income. You may be asked to provide proof of income.How many people live in your household (including yourself)?1234OtherYour household size includes allindividuals you reported on your U.S. Tax Return. If you did not file a tax return please include all individuals that live with you.No Are your combined savings, investments and real estate worth more than 29,250 if you are married and living with your spouse?YesOr worth more than 14,960 if you are not married or not living with your spouse? (Do NOT count your home, vehicles, personalpossessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.)5. Your insuranceMedicare effective date (MM/DD/YYYY)//Medicare/Medicare Advantage/Medicare Part D fMedicaidThe date is located on the front of your Medicare Card.Emergency MedicaidOther federal/state or local healthcare programs (VA/DoD,HIS)Private insurance (Commercial HMO/PPO) but the Amgen medicine or its generic/biosimilar is NOT covered.No insurance f Jump to Section 6Check all that apply:If you have Medicare Part D and have applied for Medicare’s Low Income Subsidy (Extra Help), which of the following decisions did you receive? Full supportPartial supportDeniedDid not applyYour primaryinsuranceHealthcareCoverage,Medicare,or MedicaidInsurer namePlan nameSubscriber nameYour pharmacyinsurancePrescriptionCoverage orMedicare Part DPlan phone #Relationship to patientMember ID/policy #Group #Insurer namePlan namePlan phone #--DOBPCN #Relationship to patientMember ID/policy #Group #First namePhone #Address 6. Your eligibility for government programs/MMDD/YYYYBIN #Subscriber nameYour physician’s Last nameinformation-State-ZipComplete this section only if you do not have insurance or coverage for Aimovig.If you are not enrolled in Medicaid, please provide the following reasons:Denied (provide letter of denial)Application pendingDid not applyIf your Medicaid application is pending, or if you did not apply, please answer the following:YesNo Are you pregnant?YesNo Are you legally blind or have you received a Social Security Disability status?YesNo Do you receive Social Security Disability? YesNo Are you a parent or caretaker relative of a child under the age of 18?v6-Mar-2021 PO Box 19148, Lenexa, KS 66285 Phone: 1-800-932-3060 Fax: 1-833-959-1409 amgensafetynetfoundation.com
PATIENT APPLICATIONPage 2 of 4PATIENT CERTIFICATIONAmgen Safety Net Foundation “the Foundation” is a nonprofit patient assistanceprogram that helps qualifying patients access Amgen medicines at no cost.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 Amgenmedications 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 medications given to me by the Foundation.I understand that completing the Foundation application form is not a guarantee of eligibility for the Foundation. Ialso understand that the Foundation may change or discontinue the program at any time without notice, except thatif I am enrolled in a Medicare Part D plan, my benefits will continue until the end of the calendar year. I understandthat if I am currently enrolled in a Medicare part D plan, I cannot utilize my Part D plan benefits for medicationsreceived 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. The Foundation reserves the right to change or terminate this program at any time, orto refuse to distribute Amgen medications under this program to any patient or facility.Fair Credit Reporting Act (FCRA) AuthorizationI am providing written instructions authorizing the Foundation and its vendor to obtain my consumer report from aconsumer reporting agency to be used solely for the eligibility determination process for programs administered bythe Foundation.Amgen Safety Net Foundation is not a state or federally funded program. The Foundation is sponsored solely by Amgen Inc.Amgen Safety Net Foundation does not charge patients a fee for its assistance. Amgen Safety Net Foundation is not affiliatedwith third parties who charge a fee for assistance with enrollment or medication refills. If you are being charged a monthly fee forsupport from the Amgen Safety Net Foundation, the organization billing you is not the Amgen Safety Net Foundation and you arebeing charged for support that the Amgen Safety Net Foundation can provide to you directly at no cost.This form requires a patient’s printed name, signature and date of signature in order for the Foundation to begin processing the application.Printed name of patientName of legal guardian (if needed)Signature of patient (or legal guardian) Electronic signatures not acceptedDated MM/DD/YYYYPlease proceed to the next page.v6-Mar-2021 PO Box 19148, Lenexa, KS 66285 Phone: 1-800-932-3060 Fax: 1-833-959-1409 amgensafetynetfoundation.com
PATIENT APPLICATIONPage 3 of 4PATIENT AUTHORIZATIONAmgen Safety Net Foundation “the Foundation” is a nonprofit patient assistanceprogram that helps qualifying patients access Amgen medicines at no cost.I authorize the Foundation and its contractors and business partners to use and/or disclose my personal information,including my personal health information, for the following purposes: To determine my eligibility for and assist with my continued participation in the Foundation. To contact me to seek feedback on the Foundation’s services.I understand that my personal health information may include any information, in electronic or physical form, inthe possession of or derived from a health care provider, health care plan, pharmacy, pharmaceutical company,laboratory and/or their contractor (“Health Care Provider”). This may include information from or about my medicalhistory and general health, my health care plan benefits, payment limits or restrictions covered by my health careplan policy, and/or my adherence to my treatment.I also authorize and instruct my Health Care Provider(s) to disclose my personal health information to the Foundationfor the purposes stated above.I understand that I may refuse to sign this form, but if I refuse to sign it or revoke my authorization, I will not be ableto receive assistance from the Foundation. I understand that signing this form is not a condition for receiving anymedical care outside of the Foundation assistance and that my Health Care Provider will not condition my medicaltreatment or insurance benefits on my agreement to sign this form.I understand that once I provide my personal information to the Foundation, or my Health Care Provider has providedmy personal information to the Foundation pursuant to this authorization, federal privacy laws (including HIPAA) maynot prevent redisclosure of this information; however, the Foundation has agreed to protect my personal informationby using and disclosing it only for the purposes described above or as required by law.I understand that I may receive a copy of this form at any time by contacting the Foundation at 1-800-932-3060 and Imay revoke it by mailing a revocation to PO Box 19148, Lenexa, KS 66285. A revocation must be in writing and is noteffective to the extent that action has already been taken based on this authorization.I understand that this authorization will expire one (1) year after the date it is signed below or one (1) year after thelast date I receive medication from the Foundation, whichever is later.By providing my phone number I authorize the Foundation to contact me by phone through the use of automateddialing machines and artificial or prerecorded messages for the purposes described above. I understand that thesecommunications may discuss Amgen medications and I authorize the Foundation to leave voicemail messages.This form requires a patient’s printed name, signature and date of signature in order for the Foundation to begin processing the application.Printed name of patientName of legal guardian (if needed)Signature of patient (or legal guardian) Electronic signatures not acceptedDated MM/DD/YYYYBy signing above, I am indicating that I am legally authorized to consent and that I am providing my consent as the patient or the patient’s legal guardian for theFoundation and its contractors and business partners to use and share the personal information I provide for the purposes described within the Authorization above.v6-Mar-2021 PO Box 19148, Lenexa, KS 66285 Phone: 1-800-932-3060 Fax: 1-833-959-1409 amgensafetynetfoundation.com
PRESCRIPTIONPage 4 of 4Give this page to your prescribing physician to complete and fax along with your completed application.Prescribing physician signature attesting to consent is required on this application (bottom of page)but an original prescription is also accepted in place of the prescription section on this form.Patient nameSex:FirstLastMaleFemale Date of birth/MM/DD/YYYY/Is the patient allergic to latex?YesNoIf the patient is allergic to latex, select one of the options below(selection is required for Drug Utilization Review):The needle shield within the orange cap of the Aimovig autoinjector contains dry natural rubber, which ismade from latex. In order to ship the medication(s), ourpharmacy is required to complete a Drug Utilization Review(DUR) that includes both review of other medications thepatient is taking as well as cross referencing this newmedication against any reported allergies.Patient has a true latex allergy and should not receive Aimovig Patient has tolerated latex in the past and is OK to receive Aimovig Patient has mild topical allergy to latex but can receive Aimovig PatientKnown drug allergies (Required entry. If no known drug allergies, check None.)NoneAllergies:Concurrent medications (Required entry. If no known concurrent medications, check g Medication DoseFrequency One 70 mg/ml Sureclick Every two weeks One 140 mg/ml Sureclick Once monthlyDispenseAmount12-week supplyICD-10 required ifpatient has insurance1 year or ICD-10xPhone--Prescribing physician namePhone-Street addressAimovig is shipped every 3 monthsContact nameFacility/Practice namePrescribingPhysicianPatient Diagnosis Code(erenumab-aooe) Electronic Prescription (eRX) SubmittedMedVantx NPI number – 1073692745 NCPDP number – t (PO BOX not accepted)National Provider ID (NPI)CityTax IDZIPStateBoth IDs required Provider Transaction Access Number (PTAN) Required if the patient has MedicareI have prescribed the Amgen medicine indicated above for the referenced patient. My patient gave consent for me to provide this information.I understand that no third party or patient may be billed or charged for the Amgen medicine provided by this program. I understand that nomedication received from Amgen Safety Net Foundation may be sold, traded, or distributed for sale.Prescribing physician’s signature Stamps not acceptedState license number RequiredDate signed MM/DD/YYYYThis form must be completed and submitted with the patient application but does not guarantee enrollment in or fulfillment of this prescription bythe Amgen Safety Net Foundation. Amgen Safety Net Foundation must review the complete application including this prescription or an originalscript to determine the patient’s eligibility.Fax this prescription to 1-833-959-1409v6-Mar-2021 PO Box 19148, Lenexa, KS 66285 Phone: 1-800-932-3060 Fax: 1-833-959-1409 amgensafetynetfoundation.com
possessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.) v6-Mar-2021 PO Box 19148, Lenexa, KS 66285 Phone: 1-800-932-3060 Fax: 1-833-959-1409 amgensafetynetfoundation.com
