PRODUCT REPLACEMENT REQUEST FORM

Amgen Safety Net Foundation offers replacement product for physician-administered medications. Under this model, providers administer product from their existing commercial stock to qualifying Foundation patients and then order replacement for this product from the Foundation. These products must be administered in an outpatient setting to be eligible for replacement. Use this form for the following products: • Aranesp® () • Kyprolis® (carfilzomib) • Nplate® () • Vectibix® (panitumumab) injection • EPOGEN® () • Neulasta® () • Parsabiv™ (etelcalcetide) • XGEVA® () for use only • NEUPOGEN® () • Prolia® (denosumab) injection (PMO & CTIBL use) Important reminders • Your patient must be enrolled in the Foundation.

• Request for dates of administration in the future cannot be processed.

• Replacement product may only be requested for dates of administration up to six months prior to the patient’s enrollment start date.

• For EPOGEN® the total number of administrations is required. For EPOGEN® multi-dose requests, M20 or M10 must be indicated. Multi-dose vials must accumulate 200,000 units before the product will be shipped.

• For Aranesp® the prescribing physician and their state license number are required.

• Amgen Safety Net Foundation is available for outpatient use only. Amgen Safety Net Foundation does not provide support for product administered in the hospital inpatient setting.

• All information on this form is required. Failure to complete all information will result in shipment delays.

• Fax the completed Product Replacement Request Form* to (866) 549-7239.

*This form is also available for download at www.amgensafetynetfoundation.com.

PO Box 18769 | Louisville, KY 40261-7821 | Phone: (888) 762-6436 | Fax: (866) 549-7239 | www.amgensafetynetfoundation.com Effective February 2017 Replacement Request Form V15 Page 1 of 2 PRODUCT REPLACEMENT REQUEST FORM This form can be used for the following products. Multiple patients and products may be entered on a single form if the facility customer numbers and shipping address are the same. Aranesp® (darbepoetin alfa) Kyprolis® (carfilzomib) NEUPOGEN® (Filgrastim) Parsabiv™ (etelcalcetide) Vectibix® (panitumumab) Injection EPOGEN® (Epoetin alfa) Neulasta® (pegfilgrastim) Nplate® (romiplostim) Prolia® (denosumab) injection XGEVA® (denosumab) for dialysis use only Facility Information

Facility Name ASNF Facility Customer Number (Required to verify facility. To obtain, call 1-888-762-6436)

Facility Contact Name Title Phone ( ) - Fax ( ) - First Last Shipping Address HIN DEA Street (PO BOX not accepted) City State ZIP Patient Information Fill out these columns for Aranesp® (darbepoetin alfa) and EPOGEN® (Epoetin alfa) only UOM EPOGEN® (Epoetin alfa) only Aranesp® (darbepoetin alfa) Patient name Patient Product Name Strength Quantity Administration Administration (Last, First) Date of Birth (Kit, vial, Dispensed Start Date End Date syringe, unit) Total # Multi-dose only – check one Prescriber Prescriber of Admins M20 20,000 1ML M10 20,000 2ML Name SLN

Physician Required To Initial Each Line I certify that the Amgen product reported on this form, for which I am requesting free replacement, was furnished free of charge to the designated Amgen Safety Net Foundation patient. I further certify that I will not charge or cause any other party to charge any third party or patient for Amgen products for which replacement is sought under Amgen Safety Net Foundation and that no part of any charges for Amgen products replaced under Amgen Safety Net Foundation will be claimed as bad debt. 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 understand that Amgen Safety Net Foundation is available for outpatient use only. I certify that no replacement was requested for product administered in the hospital inpatient setting. I authorize this replacement 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, the Foundation reserves the right to audit any enrolled facility with a 30-day advance notice.

Physician Signature Date Signed Printed First Name Printed Last Name Signing Physician State License Number

*This form is also available for download at www.amgensafetynetfoundation.com.

PO Box 18769 | Louisville, KY 40261-7821 | Phone: (888) 762-6436 | Fax: (866) 549-7239 | www.amgensafetynetfoundation.com Effective February 2017 Replacement Request Form V15 Page 2 of 2