PROVIDER TIP SHEET: ENROLLMENT FOR REPLACEMENT PRODUCTS

Products available for Replacement: Aranesp® (), EPOGEN® () for dialysis use only, Kyprolis® (carfilzomib), Neulasta® (), NEUPOGEN® (), Nplate® (romiplostim), Prolia® () injection, Parsabiv™ (etelcalcetide), Vectibix® (panitumumab) injection, and XGEVA® (denosumab). These products must be administered in an outpatient setting to be eligible for replacement.

Amgen Net Foundation may be able to help Safety Net Foundation is a nonprofit patient assistance program that helps qualifying uninsured patients access Amgen medicines at no cost. Amgen Safety Net Foundation offers replacement product for certain physician-administered products. Under this model, providers administer Amgen product from their existing commercial stock to qualifying Foundation patients and then order replacement for the product from the Foundation.

Your patient may be able to receive Amgen medications at no cost from Amgen Safety Net Foundation if they meet the following eligibility requirements:

 Resident of the US or its territories  Satisfy income eligibility requirements below  Have no or limited drug coverage  Do not have any other insurance or financial support options  Available for outpatient use only

If you have this many people in …your income must be at or below this household… much each year

1 $60,300 2 $81,200 3 $102,100 4 $123,000 Each Additional Person Add $20,900

How does my patient apply? Step 1: Access the Patient Application Form for Physician Adminsitered Products  Go to www.amgensafetynetfoundation.com and click on the Forms tab Step 2: Have your patient complete pages 1-3 of the application  If your patient needs help filling out this form, they can call us at 1-888-762-6436 to speak to one of our Patient Assistance Counselors Step 3: Send the completed application  Review the application to make sure you and your patient have filled in every field  Fax the application to 1-866-549-7239

When will I hear if my patient is approved? Once we receive and process the completed application and any requested supporting documents, the patient and the provider will be notifed of the enrollment decision. Missing information or an incomplete application will delay an enrollment decision.

How do I receive product for my patient? Once your patient is enrolled in the Foundation and you have administered product to the patient you may begin requesting replacement product by submitting the Product Replacement Request Form. For more information on requesting Product Replacement you can reference the Product Replacement request tip sheet on our website at www.amgensafetynetfoundation.com by clicking on the Resources tab.

If you have other questions: Go to www.amgensafetynetfoundation.com and click on the Resources tab for answers to Frequently Asked Questions and other Tip Sheets. You can also talk to one of our Patient Assistance Counselors by calling 1-888-762-6436, Monday through Friday, 9am to 8pm Eastern Time.

PO Box 18769 Louisville, KY 40261-7821 | Phone: (888) 762-6436 Fax: (866) 549-7239 | www.amgensafetynetfoundation.com Effective October 2017 Revision ASNF Provider Physician Administered Application V13 Page 1 of 1