Bristol Myers Squibb - Eliquis Assistance Form: http://www.bmspaf.org/Documents/BMSPAF . You are encouraged to report negative side effects of prescription drugs to the FDA. Please see full Prescribing Information. The Bayer US Patient Assistance Foundation is a charitable organization that helps eligible patients get their Bayer prescription medicine at no cost. 1 Conditions. Let us know if either of the To operate, administer, enroll me in, and/or continue my participation in Amgens. Decide on what kind of eSignature to create. Then click on the first letter of the name of your medicine in the alphabet bar. I understand that by signing this form, I authorize my Health Care Providers or others who might hold my health information to only release it to Amgen employees, as well as to its contractors and (evolocumab) Copay Card Terms and Conditions. Getting Started with Repatha Universal Authorization Form This simple form collects the patient privacy authorization, allowing the Repatha Access Specialist to provide personalized follow-up and support for patients using a specialty pharmacy or the RepathaReady hub. I Based assistance program, amgen patient form changed but not revealing or in patients access to severe if you have selected will keep you away from this authorization. develop, and evaluate products, services, materials, and programs related to If you believe your commercial insurance plan may have such limitations, or if you have questions regarding the annual maximum dollar limit, please call 1-844-REPATHA. Stop taking Repatha and call your healthcare provider or seek emergency help right away if you have any of these symptoms: trouble breathing or swallowing, raised bumps (hives), rash or itching, swelling of the face, lips, tongue, throat or arms. or Fax all completed, signed forms to 1-844-855-7278 or mail to PO Box 592188, Orlando, FL 32859-2188 If you have insurance, fill out the Insurance Information section . Administrators are prohibited from assisting patients with enrollment in A RepathaReady nurse* will Tell your healthcare provider if you have any side effect that bothers you or that does not go away. Since 2005, we've helped more than 500,000 people get free access to the medicines they. asking your doctor about a prescription, RepathaReady The Amgen Privacy Statement prescription costs for Repatha, The Maximum Monthly Benefit will apply every month except that the The lowest GoodRx price for the most common version of Repatha is around $512.90, 14% off the average retail price of $598.12. The single-dose Pushtronex system (on-body infusor with prefilled cartridge) is not made with natural rubber latex. The Novo Nordisk Diabetes Patient Assistance Program (PAP) provides medication to qualifying applicants at no charge. Participation is not a guarantee of insurance coverage. Enrollment in the copay program is not ongoing and in order to remain eligible, patient must re-enroll when notified by Amgen by visiting Repatha.com/reenroll. Medicaid, TRICARE, Department of Defense, or Veteran Affairs programs), Amgen agrees, however, to protect my If you have questions regarding these terms and conditions or the Repatha Copay Card program, please call 1-844-REPATHA. Check your spam The information provided by me on this application form is true and accurate; 2. Before you start using Repatha, tell your healthcare provider about all your medical conditions, including if you are allergic to rubber or latex, are pregnant or plan to become pregnant, or are breastfeeding or plan to breastfeed. 2 basis, my cancellation with Amgen will be effective with respect to any such Health Care Providers as soon as they receive notice of my cancellation. Phone: 1-800-727-5400. The patient's insurance must cover the qualifying medication that they are seeking assistance for. If you want to connect with a Repatha Sales Representative, select the box below the form to schedule a virtual or in-office visit. Check your spam Adverse Reactions in Primary Hyperlipidemia: The most common adverse reactions (>5% of patients treated with Repatha and more frequently than placebo) were: nasopharyngitis, upper respiratory tract infection, influenza, back pain, and injection site reactions. personal health information by only using and disclosing it as stated in the Authorization or as otherwise allowed or required by law. They are not part of your treatment team or an extension of your doctors office. I authorize Amgen and its contractors and business partners ("Amgen") to use and/or disclose my personal information, including my personal health information, only for the following purposes: In order for Amgen to provide me with the services and/or programs described above, Amgen needs to collect and use my personal information, including my personal health information. out-of-pocket and may pay $5 per month*. However, there may be other ways to lower your out-of-pocket costs. Repatha information program and related activities; to asperger internet addiction. Restrictions I am also agreeing, by checking this box, to Amgen calling and texting me at the phone number(s) I have provided with promotional communications relating to Amgen products and services and/or my condition or treatment. Patient Assistance Program PO Box 0367, Chesterfield, MO 63006 Dont see it in your inbox? By checking the I Agree box, I am electronically indicating that I 4. Box 503227 , San Diego, CA 92150 Amgen will continue discussions with the FDA regarding the 420 mg every two weeks dosing for HoFH patients. folder. All product names, logos, brands, trademarks and registered trademarks are property of their respective owners. This is a copay assistance program for patients that have health insurance. Select a medication below to learn about our . Reply HELP for help, STOP to cancel (standard text messaging rates may apply). Repatha via mobile phone text messages. If you believe your commercial insurance plan may have such this program means that you are ensuring you comply with any required Application just visit www.REPATHA.com or call repatha patient assistance form pdf ( 1-844-737-2842 ), Monday - Friday 8am - 9pm ET enrollment. I understand I do not have to sign this Authorization and that my enrollment in any of the services and/or programs described above is entirely voluntary. notice. To see if you are eligible, you will need to complete Patient Sections 1-5 on the Patient Application: Patient Section 1: Fill out your information completely and accurately. Application / 1 Bayer understands that sometimes people face financial challenges, and we are here to help. To contact, with my permission, my doctor and the rest of my health care team and share with them my health information that may be useful for my care; To improve, develop, and evaluate products, services, materials and programs related to my condition or treatment. Privacy Statement Get the Takeda Patient Assistance Program Online Application Form you need. I am agreeing, by checking this box, to Amgen calling and texting me Find patient applications along with provider forms such as product prescription forms, on demand product request forms and product replacement request forms. and consent to Amgen contacting me using the contact information provided in The needle covers on the single-dose prefilled syringes and the inside of the needle caps on the single-dose prefilled SureClick autoinjectors contain dry natural rubber. Do you have commercial or private healthcare insurance? Applications should be faxed or mailed directly to the PAP, not to NeedyMeds. Nurse support is available in other languages, including Spanish. 2021 Amgen Inc. All rights reserved. authorized to consent, and that I am providing my consent as the patient or the BI Cares Patient Assistance Program - Gilotrif . This program helps eligible patients cover out-of-pocket costs It is not valid for cash-paying For more information, call This offer is only valid in the United States, Puerto Rico, and the US territories. NOTICE: The RepathaReady mobile Short Message Service (SMS) program for Repatha (evolocumab) is not intended to be a source of medical advice or care. NYS Epic Application: https://www.health.ny.gov/forms/doh-5080.pdf 2. Patients with these plan limitations are not eligible for the Repatha Copay Cardbut may be eligible for other needs-based assistance provided by Amgen. Health insurance you or a family member purchased and/or receive through an employee, healthcare exchange or commercial plan through the Federal Employees Health Benefits (FEHB) Program, Includes Medicare Part D, Medicaid, TRICARE, Department of Defense, or Veteran Affairs Program, You must agree to Eligibility Information Terms and Conditions to enroll, and 6 messages per month from mobile short code 72328, and a mobile opt-in request message from 72328, email and confirm-email are not The Repatha Copay Card also may provide a reduced benefit amount, unilaterally determined by Amgen in its sole discretion, to satisfy the out-of-pocket cost-sharing requirement for any patient whose plan or plan agent (including, but not limited to, a Pharmacy Benefit Manager (PBM)) requires enrollment in the Repatha Copay Card as a condition of the plan or PBM waiving some or all of an otherwise applicable patient out-of-pocket cost-sharing amount. call you within just a few days of signing up to BI Cares Patient Assistance Program - Ofev . RepathaReady offers resources and support services to help patients stay on track with their high LDL treatment. Reference: 1. I authorize Amgen and its contractors and business partners (Amgen) to use and/or disclose my personal information, including my personal health information, only for the following purposes: In order for Amgen to provide me with the services and/or programs described above, Amgen needs to collect and use my personal information, including my personal health information. and provides support services. If you would like to change your reminders, or if you have any questions, please call 1-844-REPATHA (1-844-737-2842) for assistance. Box 503227 , San Diego, CA 92150 Call RepathaReady at 1-844-REPATHA (1-844-737-2842) to see if you qualify for the Repatha Copay Card. A patient is considered cash-paying where the patient has no insurance coverage for Repatha or where the patient has commercial or private insurance but Amgen in its sole discretion determines the patient is effectively uninsured because such coverage does not provide a material level of financial assistance for the cost of a Repatha prescription. The Novo Nordisk Patient Assistance Program (PAP) is based on our commitment to our patients. payment limits or restrictions covered by my health care plan policy, and/or my adherence to my treatment. What is Repatha Patient Support Program? Amgen may contact me using the contact information provided in this form for participation in market research activities associated with Amgens products, services, and/or my condition or treatment. Hypersensitivity Reactions: Hypersensitivity reactions, including angioedema, have been reported in patients treated with Repatha. Adverse Reactions in the Cardiovascular Outcomes Trial: The most common adverse reactions (>5% of patients treated with Repatha and more frequently than placebo) were: diabetes mellitus (8.8% Repatha, 8.2% placebo), nasopharyngitis (7.8% Repatha, 7.4% placebo), and upper respiratory tract infection (5.1% Repatha, 4.8% placebo). Patient assistance program patient ID Number: Contact Name: Phone Number: M6453(REPAPRAL)-8/20 (Continued on next page) Page 2 of 7. Amgen may in its discretion change or suspend the Service (defined below) at any time. If you are a healthcare professional, click I Agree to continue. You agree to notify Amgen if at any time your answers to any of these questions change. We're here to help! Do you have a question about Repatha or need for the purposes described above. Information Received from Health Care Providers Providers, cannot require me, as a condition of having access to medications, prescription drugs, treatment or other care, to sign this Authorization. EVOLOCUMAB treats high cholesterol. patient assistance program that helps qualifying patients access Amgen medicines at no cost. Copy of W-2 or 1099 Form Copy of Unemployment Benefit statement Medicaid Eligibility Form (if appropriate) Medicare Part D out-of-pocket . If you are a healthcare professional, click I Agree to continue. I understand I cannot participate in the listed services and/or programs without signing this Authorization or Which type of insurance do you use to pay for your Repatha prescription? I understand that the PAP/MAP reserves the right to modify the application form, modify or discontinue this program, or terminate assistance at any time and without notice. I authorize the PAP/MAP and its administrator to forward my prescription . where the patient has no insurance coverage for Repatha or RepathaReady offers helpful resources to Repatha HMSA - 12/2021. . If at any time patient begins receiving coverage under any such federal-, state-, or government-funded healthcare program, patient will no longer be able to use this offer and patient must call 1-844-REPATHA to stop participation. Page 2 of 7. This site is intended for U.S. residents only. This Application Form is for patients who would like to apply to receive the available medication(s) at no cost through the Program. In addition to educational emails, nurse support, and insurance assistance, RepathaReady offers other useful services to help you on the path to dramatically lower LDL bad cholesterol and reduce your risk of heart attack or stroke. The patient, or his/her legal representative, must personally enroll in the In addition, if at any time you become enrolled in a plan that provides prescription drug coverage under any Medicare or any other federal or state government program, you will no longer be able to use this card and must stop your participation in the program. 3 It is important that every patient read and understand the full Repatha (evolocumab) Copay Card Terms and Conditions. This site is intended for US healthcare professionals only. You can If you would like to receive support, information, and updates from Repatha, sign up for emails and SMS (text) below. can contact Amgen by calling 1-844-REPATHA (1-844-737-2842) or by writing to If Yes, name of program or other source: Provide details and attach documentation of acceptance or decline: 1. REPATHA can cause serious side effects including: . limitations, please contact RepathaReady at 1-844-REPATHA (1-844-737-2842). Serious hypersensitivity reactions including angioedema have occurred in patients treated with Repatha. who meets eligibility criteria may pay as little as a $5 Copay per month CHECKLIST FOR SUBMITTING AN APPLICATION IF YOU ARE THE PRESCRIBER, COMPLETE PAGE 2 o SECTION 1: Prescriber Information o SECTION 2: Patient Information o SECTION 3: Product information - Please choose medication from list on Page 5. The most common injection site reactions were erythema, pain, and bruising. Call your healthcare provider for medical advice about side effects. Check this box to be connected to a Repatha Sales Representative regarding Either the card number you entered is invalid or your card has already been activated. exchanges. Youve successfully activated your Repatha Copay Card. PATIENT APPLICATION Page 2 of 4 v10-Apr-2022 PO Box 19148, Lenexa, KS 66285 Phone: 1-800-932-3060 Fax: 1-833-959-1409 amgensafetynetfoundation.com I certify that: The information I provided on the Foundation application form is complete and accurate. When a statin cannot be used or does not work well, Repatha can be used alone or together with other cholesterol lowering medicines. How often are you prescribed to take your Repatha? Do you have a Repatha prescription? Serious hypersensitivity reactions including angioedema have occurred in patients treated with Repatha. If you are dissatisfied with the Service or the content received through the Service, your sole remedy is to discontinue use of the Service. You will receive a mobile opt-in request message from 95093 and a mobile opt-in request message from 72328. The Johnson & Johnson Patient Assistance Foundation, Inc. (JJPAF) is an independent, nonprofit organization. Based on your answers, you do not qualify for the Repatha Copay Card at this time. Choose My Signature. addition of any coverage terms that do not apply Repatha. Sorry! Health plans, specialty pharmacies, and Pharmacy Benefit Managers (individually and collectively Plan Administrators) are prohibited from enrolling patients in the Repatha Copay Card. These programs are Create your eSignature and click Ok. Press Done. I also understand I am authorizing my personal information, including my personal health information, to be used By exiting the page, my activation and enrollment into RepathaReady will be discontinued. If I If you do not have access to a fax machine, please mail documents to the Amgen Patient Assistance Program for Otezla at P.O. These programs are often referred to as copay maximizer programs. Patient may not seek reimbursement for value received from this offer from any third-party payers, including flexible spending accounts or healthcare savings accounts. I give consent to the Program to disclose my enrollment in the Program as needed to comply with legal and regulatory obligations; 1 Open to patients 18 years or older with commercial prescription insurance and who are not enrolled in any government-funded program that pays for prescription drugs. Repatha can cause serious side effects including, serious allergic reactions. Message and Data Rates May Apply. This is a copay assistance program: Provided by: Patient Access Network Foundation: TEL: 866-316-7263 FAX: 866-316-7261: Languages Spoken . This site is intended for US healthcare professionals only. The needle covers on the single-dose prefilled syringes and the inside of the needle caps on the single-dose prefilled SureClick autoinjectors contain dry natural rubber. This form is currently under maintenance. 2, I agree to receive SMS messages related to Repatha. *. you will not receive information related to other patient support services. requirement to participate in this program. Sign up today to see if you are eligible for the Repatha Copay Card, and to receive nurse support, needle disposal containers, medication reminders and informational emails, and insurance assistance. information, for the following purposes only: To operate, administer, enroll me in, and/or continue my participation in Amgens It is used alone or with other medicines. Please do not press the back button or refresh the page until you have received a confirmation message. The best place to access and work with this form is here. matching, Eligibility Information and Terms and Conditions, Mobile Terms and LDL-C = low-density lipoprotein cholesterol; MI = myocardial infarction. 3 What are the possible side effects of Repatha? As with all therapeutic proteins, there is potential for immunogenicity with Repatha. I understand that I am not required to provide this consent as a condition of purchasing any goods or services. To enroll in RepathaReady Reminders or receive subscription messages: Visit Repatha.com or call 1-844-737-2842. If patient qualifies, the Repatha Copay Card may cover out-of-pocket costs for Repatha up to an annual maximum dollar limit. For injection information, have patients visit www.RepathaInjection.com. Download our LDL Guide to keep track of your bad cholesterol number (measured mg/dL) as you go forward on Repatha. Your re-enrollment period begins 60 days prior to your expiration date. Patients may not seek reimbursement for the value received from the Please enter a correctly formatted Email Address, Please enter a valid 10-digit Phone Number. For assistance with our program, please call our toll-free number Monday - Friday from 8:30 a.m. - 6:00 p.m. Eastern time: BI Cares Patient Assistance Program (includes a number of medicines) 1-800-556-8317. CVD = cardiovascular disease; LDL-C = low-density lipoprotein cholesterol; MI = myocardial infarction. It looks like youre re-enrolling too soon. Terms and conditions apply. This Patient Information has been approved by the U.S. Food and Drug Administration. pharmaceutical company, laboratory and/or their contractor (Health Care Provider). I also understand that if a Health Care Provider is disclosing my personal health information to Amgen on an authorized on-going basis, my cancellation with Amgen will be effective with respect to any such Health Care Providers as soon as they receive notice of my cancellation. Prescription Settings brand sureclick 1ml of 140mg/ml 2 sureclicks T-Mobile is not liable for delayed or undelivered messages. Do not use Repatha if you are allergic to evolocumab or to any of the ingredients in Repatha . Yes No Is Repatha prescribed by, or in consultation with, a cardiologist, endocrinologist or neurologist? 1-844-REPATHA (1-844-737-2842).
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