repatha patient assistance application form pdf

you will not receive information related to Ask your healthcare provider or pharmacist for more information. and consent to Amgen contacting me using the contact information provided in If you have questions about your Repatha Copay Card, please call 1-844-REPATHA. If you are a healthcare professional, click I Agree to continue. Takeda Patient Assistance Program P.O. 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). Privacy Statement. CVD = cardiovascular disease; LDL-C = low-density lipoprotein cholesterol; MI = myocardial infarction. PDF Drug Prior Authorization Form - Repatha (evolocumab) - Canada Life required to provide this consent as a 3 XARELTO is indicated for the reduction in the risk of recurrence of DVT and/or PE in adult patients at continued risk for recurrent DVT and/or PE after completion of initial treatment lasting at least 6 months. applicable patient out-of-pocket cost-sharing amount. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088. Patient Assistance Program (PAP) or Medication Assistance Program (MAP) Eligibility Screening 5. . provide me with informational and promotional materials relating to Amgen Want to revise or patient application form element changed but not result in. The Repatha Copay Card helps provide out-of-pocket support to When would you like your first refill reminder? patient assistance program that helps qualifying patients access Amgen medicines at no cost. limits. along with diet alone or together with other cholesterol-lowering medicines in adults with high blood cholesterol levels called primary hyperlipidemia (including a type of high cholesterol called heterozygous familial hypercholesterolemia [HeFH]) to reduce low-density lipoprotein (LDL) or bad cholesterol. The single-dose Pushtronex system (on-body infusor with prefilled cartridge) is not made with natural rubber latex. for their Repatha monthly out-of-pocket costs. LDL-C = low-density lipoprotein cholesterol; MI = myocardial infarction. Sign Up for RepathaReady or Call 1-844-REPATHA (1-844-737-2842), 9 AM-11 PM ET. related to Repatha, up to program limits. 4. The Novo Nordisk Patient Assistance Program (PAP) is based on our commitment to our patients. additional informational and marketing communications related to my condition Horsham, PA 19044-9979. You will receive only the most important resources and Patient Assistance Program Phone Number - 855-210-6228 for instructions. Let our nurses provide personal support related to your financial coverage and referrals to resources that may help your emotional wellness. Patient with Medicare Part D will be considered on a case by case basis. apply). 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. Were sorry, there was an error processing your request. When prescribing Repatha, a drop-down list will appear to select the administration method Please note Repatha SureClick is the first option on the drop-down Be sure to review the administration choice before submitting the PA request Selecting the correct PA form Choose the Patient Insurance State in the drop-down list. I understand that I am not required to provide this consent as a condition of purchasing any goods or services. To report an adverse event, please call 1-800-77-AMGEN (1-800-772-6436). offers helpful resources, including the Copay Card for eligible commercially insured patients, to Contraindication: Repatha is contraindicated in patients with a history of a serious hypersensitivity reaction to evolocumab or any of the excipients in Repatha. It is important that every patient read and understand the full Repatha Hypersensitivity reactions occurred in 5.1% and 4.7% of Repatha-treated and placebo-treated patients, respectively. Furthermore, you can find the "Troubleshooting Login Issues" section which can answer your unresolved problems and equip you with a lot of relevant information. Reference: 1. personal health information by only using and disclosing it as stated in the Authorization or as otherwise allowed or required by law. Patient Assistance Program Enrollment Form I am a Medicare patient with prescription coverage and I meet the income restrictions described below Do I qualify for PASS? 1. Patient assistance programs (PAPs) are usually sponsored by pharmaceutical companies and provide free or discounted medicines and copay programs to low income or uninsured and under-insured people . Authorization to Contact The most common injection site reactions were erythema, pain, and bruising. fills of the Repatha, A program benefit that covers the patients eligible out-of-pocket prescription costs for Repatha, The Maximum Monthly Benefit will apply every month except that the From a pool of the 52-week trial and seven 12-week trials: Local injection site reactions occurred in 3.2% and 3.0% of Repatha-treated and placebo-treated patients, respectively. Please check back tomorrow or call 1-844-REPATHA (1-844-737-2842), Monday - Friday 8am - 9pm ET for enrollment assistance. For more information about Amgen's privacy practices, please visit www.amgen.com/privacy. you or your spouses employer, you may lower your 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. Repatha can cause serious side effects including, serious allergic reactions. Hypersensitivity Reactions: Hypersensitivity reactions, including angioedema, have been reported in patients treated with Repatha. As with all therapeutic proteins, there is potential for immunogenicity with Repatha. Open it up using the cloud-based editor and start adjusting. Do not use Repatha if you are allergic to evolocumab or to any of the ingredients in Repatha. 2022 Amgen Inc., All rights reserved. Registration for this program is closed at the moment. repatha patient assistance form pdf - labpsych.upol.cz Based on your answers, you do not qualify for the Repatha Copay Card at this time. repatha-ready Follow the texting prompts to JOIN. The best place to access and work with this form is here. Serious hypersensitivity reactions including angioedema have occurred in patients treated with Repatha. The information provided by me on this application form is true and accurate; 2. The single-dose Pushtronex system (on-body infusor with prefilled cartridge) is not made with natural rubber latex. Whether you have product-related questions or need Repatha samples, Repatha Sales Representatives are here to help you and your office staff. I also understand that if a Health Care Provider is disclosing my personal health information to Amgen on an authorized on-going **RepathaReady Nurses are nurses by training. caregivers with helpful information regarding their treatment plan and do not provide medical advice or case management services. this form to enroll me in, operate, and administer the Repatha A RepathaReady nurse* will RepathaReady Registration | Repatha (evolocumab) REMICADE is indicated for reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active ulcerative colitis (UC) who have had an inadequate response to conventional therapy. You may qualify to receive PRALUENT at no cost through the PAP Program. If you are being charged a monthly fee for support from the Amgen Safety Net Foundation, the organization billing you is not the . In many cases the program application form can be printed from our website. Repatha is an injectable prescription medicine used: This information is intended only for U.S. healthcare professionals. In addition to the Patient Authorization below, I understand that by checking this box, I am also enrolling into the RepathaReady patient support program. Do you understand and agree with this statement? BI Cares Patient Assistance Program - Gilotrif . (individually and collectively Plan Administrators) are prohibited from Program Applications and Forms: Repatha Free Needle-Disposal Container Program: Contact program : Medications: Repatha disposal container (container for repatha sharps) . patient assistance program that helps qualifying patients access Amgen medicines at no cost. The patient, or his/her legal representative, must personally enroll in the Patient Assistance | Amgen Canada Forms FAQs Provider Access Brochure Patient re-certification and authorization form. Form more information phone: 844-737-2842 or Visit website. Ask your healthcare provider or pharmacist for more information. conditions, the Repatha Copay Card is open to patients who have a Repatha Copay Card from any third-party payers, including a If at any time a patient begins receiving prescription drug coverage under any state or government program (including but not limited to Medicare, Medicaid, TRICARE, Department of Defense, or Veteran Affairs programs), the patient will no longer be able to use this card and they must contact RepathaReady at 1-844-REPATHA (1-844-737-2842) (Monday through Sunday, from 9am to 11pm ET) to stop their participation in this program. Patient Assistance Information - RxHope Instructions for Use Pushtronex System, RepathaReady, Sign up today for patient-focused tools and support, In adults with established cardiovascular disease to reduce the risk of myocardial infarction, stroke, and coronary revascularization, As an adjunct to diet, alone or in combination with other low-density lipoprotein cholesterol (LDL-C)-lowering therapies, in adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH) to reduce LDL-C. If you have any questions, please contact 1-844-REPATHA (1-844-737-2842). To operate, administer, enroll me in, and/or continue my participation in Amgens RepathaReady. Plan Administrators are prohibited from assisting patients with enrollment in the Repatha Copay Card. This is a copay assistance program for patients that have health insurance. Patient assistance program patient ID Number: Contact Name: Phone Number: (Continued on next page) M6453(REPATHA)-8/19. This offer is only valid in the United States, Puerto Rico, and the US territories. notice. These are not all the possible side effects of Repatha. Phone: 1-800-727-5400. Johnson & Johnson Patient Assistance Foundation, Inc can be found at http://www.amgen.com/privacystatement. Oct,2022. Be sure to bring the email or a copy of this page with you to the pharmacy. PRALUENT is an injectable prescription medicine used: in adults with cardiovascular disease to reduce the risk of heart attack, stroke, and certain types of chest pain conditions (unstable angina) requiring hospitalization. Patients who are approved for the PAP may qualify to receive free diabetes medicine from Novo Nordisk. Please see full Prescribing Information. personal health information and/or for using my information to contact me with communications about Amgen products which have been prescribed to me (for example medication reminder programs) and There is no income This program helps eligible patients cover out-of-pocket costs related to Repatha, up to program limits. Reduce Risk of MI & Stroke in CVD Patients | Repatha (evolocumab) Bausch Patient Assistance Program Application PDF Form - signNow 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. Be sure to bring the email or a copy of this page with you to the pharmacy. 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 business partners, who are performing the services set forth in this Authorization. >. Connect With a Rep COVERAGE INFORMATION Your patients count on you. I am agreeing, by checking this box, to Amgen calling and texting me Tell your healthcare provider if you have any side effect that bothers you or that does not go away. We're here to help! Sorry! Repatha via mobile phone text messages. Please check one of the boxes below. 2022 Amgen Inc., All rights reserved. Amgen's patient assistance programs provide a variety of support services for patient prescribed Amgen medications as well as financial support for qualifying patients who are uninsured or underinsured with limited financial resources. ID: You will receive an email with your Repatha Copay Card. providing my consent as the patient or the patients legal guardian for Amgen and its contractors and business partners to use and share the personal information I provide for the purposes described within the The Bayer US Patient Assistance Foundation is a charitable organization that helps eligible patients get their Bayer prescription medicine at no cost. This form is currently under maintenance. sole discretion determines the patient is effectively uninsured because you so we can personalize the information you receive from us: Have you ever had a heart attack?Before starting Repatha, have you ever had a heart attack? I understand that once my personal health information has been disclosed to Amgen, federal privacy laws may no longer apply and protect it from further disclosure. 3 RepathaReady offers resources and support services to help patients stay on track with their high LDL treatment. Please answer the questions below to see if you are eligible for the Repatha Copay Card. $20 - $580. The most common hypersensitivity reactions were rash (1.0% versus 0.5% for Repatha and placebo, respectively), eczema (0.4% versus 0.2%), erythema (0.4% versus 0.2%), and urticaria (0.4% versus 0.1%). Text HELP to 72328 for help, STOP to 72328 to cancel. I understand that I am not required to provide this With the Repatha Copay Card , eligible commercially insured patients may pay $5 per month. Information Received from Health Care Providers. The list price for Repatha is $519.82* , per month. patients legal guardian for Amgen and its contractors and business partners to use and Do you have a question about Repatha or need Bristol-Myers Squibb Patient Assistance Foundation PO Box 220769 Charlotte, NC 28222-0769 . prescription is paid for in whole or in part by Medicare, Medicaid, or Repatha Sales Representatives are here to answer any Patients must be at or below 400-500% of the federal poverty . Download our doctor discussion guide to get the most from your Repatha treatment with the help of your doctor. (evolocumab) Copay Card Terms and Conditions.

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