Amgen Safety Net Foundation is a nonprofit organization that helps qualifying patients access Amgen medicines at no cost. PATIENT INSTRUCTIONS To apply for support you must: 3 Be prescribed Blincyto (blinatumomab) for injection 3 Live in the United States, American Samoa, Guam, Puerto Rico, or the U.S. Virgin Islands 3 Have no for or no access to other coverage or funding for Blincyto 3 Have an income at or below these amounts: If you have this many people in your household More than four? your household income must be at or below this much each year $60,300 $81,200 $102,100 $123,000 Add $20,900 for each extra person 3 Complete the PATIENT INFORMATION SECTION (pages 1-2) of the application All must be reported, including Medicare, Medicaid, or other government programs If you have, 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) 549-7239 1. Your information PATIENT INFORMATION SECTION 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 Blincyto Application V2 Page 1 of 4
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) 1 2 3 4 More than 4, print # Medicare 4. Your eligibility for government programs 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) Medicaid Other Yes No Do you have Medicaid? If yes, is it Emergency Medicaid? Yes No (You MUST provide your Medicaid information even if you only have Emergency Medicaid) Yes No Have you been (If you said yes, you MUST provide 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) 5. Your Select the statement that applies I do not have I have but the Amgen product is not covered I have with a high out-of-pocket cost to your status: (If you do not have, you may skip this section. If you have health, 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 (Medicare, Medicaid, or Health Coverage) Your secondary (Supplemental) Your pharmacy (Medicare Part D or Prescription Coverage) 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 Blincyto Application V2 Page 2 of 4
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 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 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 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 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 Blincyto Application V2 Page 3 of 4
FACILITY AND PRESCRIBING PHYSICIAN INFORMATION SECTION (Your provider must fill this out) Patient Product Facility Pharmacy Director Patient name Date of birth / / Blincyto (blinatumomab) injection The physician must complete the On-Demand Product Request Form for delivery in advance of administration. Free-Standing Dialysis Center Hospital Dialysis Center Facility Safety Net Customer Number (Required to complete enrollment. To obtain, call 1-888-762-6436) National Provider ID (NPI) Tax ID HIN Pharmacy Director Name mm dd yy Infusion Facility Specialty Hospital Community Hospital Hospital Pharmacy Provider s Office Pharmacy Other Facility Name Facility Contact Detail Facility Contact Name Street Address Street (PO BOX not accepted) City State ZIP Title Prescribing Physician Prescribing Physician Name Street Address National Provider ID (NPI) Street (PO BOX not accepted) City State Provider Transaction Access Number (PTAN) (Required if the patient has Medicare) 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 Blincyto for the Patient 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 an verification may be required to determine a patient s eligibility for the Foundation. I understand that the product received through the Foundation is for eligible Foundation patients living in the United States and its territories. I certify that I will not charge, or cause anyone else to charge any third party, or the patient for Blincyto requested from the Foundation. I further certify that any Blincyto received from the Foundation will be furnished free of charge to the Patient for his/her treatment; and, that no part of any charges for Blincyto provided by the Foundation will be claimed as bad debt. I certify that any Blincyto received from the Foundation that is not used to treat the Patient will be returned to the Foundation, or my facility will reimburse the Foundation at the current Wholesale Acquisition Cost (WAC) value of Blincyto. 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. ZIP Signature of Facility Contact Printed Name of Facility Contact Date Signed Effective February 2017 Blincyto Application V2 Page 4 of 4
Amgen Safety Net Foundation offers shipment in advance of administration for Blincyto (blinatumomab) ON-DEMAND PRODUCT REQUEST FORM FOR BLINCYTO Under this model the provider submits the On-Demand Product Request Form* after the patient is enrolled at Amgen Safety Net Foundation. Product is shipped directly to the provider in advance of administration for enrolled patients. 3 All information on this form is required. Incomplete requests will not be processed. 3 Your patient must be enrolled in Amgen Safety Net Foundation. 3 Request for administration in the past will not be processed. 3 Multiple patients may be entered on a single form if the Amgen Safety Net Foundation facility customer number and shipping address are the same. 3 Fax this completed On-Demand Product Request Form* to (866) 549-7239. Facility Information Facility Name ASNF Facility Customer Number (Required to verify facility. To obtain, call 1-888-762-6436) Facility Contact Name Title Shipping Address HIN DEA Patient Information Street (PO BOX not accepted) City State ZIP Blincyto is shipped with a quantity not to exceed a 1 (one) week supply. The physician must submit a signed request form each week and include the scheduled administration dates and dates of administration for the previous week. Blincyto will only be shipped with a physician signature. Patient name (, ) Patient Date of Birth Product Name UOM Strength Quantity Ordered Scheduled Administration Date Date of Administration Blincyto Physician Required To Initial Each Line Blincyto I certify that I will not charge, or cause anyone else to charge any third party, or the patient for Blincyto requested from the Foundation. I further certify that any Blincyto received from the Foundation will be furnished free of charge to the Patient for his/her treatment; and, that no part of any charges for Blincyto provided by the Foundation will be claimed as bad debt. I certify that any Blincyto received from the Foundation that is not used to treat the Patient will be returned to the Foundation, or my facility will reimburse the Foundation at the current Wholesale Acquisition Cost (WAC) value of Blincyto. 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 authorize this 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, it 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 www.amgensafetynetfoundation.com. Effective February 2017 Blincyto On Demand Request Form V2 Page 1 of 1