repatha patient assistance application form pdf

What are the possible side effects of Repatha? limited to, initiation of insurance provided by the government, the JJPAF gives eligible patients free prescription medicines donated by Johnson & Johnson companies. If not, go back and agree, or continue Please check back tomorrow or call 1-844-REPATHA (1-844-737-2842), Monday - Friday 8am - 9pm ET for enrollment assistance. Your re-enrollment period begins 60 days prior to your expiration date. Authorization to Contact 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. costs for any patient whose selected coverage option under their Select Go Back below to choose what type of reminders you would like. I understand that I am not required to provide this Provider Phone: If you believe your commercial insurance plan may have such limitations, please contact RepathaReady at 1-844-REPATHA (1-844-737-2842). the Repatha Copay Card. Per prescription until program expires. product-related questions. Restrictions may apply. NOTICE: The RepathaReady mobile Short Message Service (SMS) program for Repatha (evolocumab) is not intended to be a source of medical advice or care. Has the patient been adherent to therapy and is continuing a low-fat diet and exercise regimen? 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. With the Repatha Copay Card , eligible commercially insured patients may pay $5 per month. (evolocumab) Copay Card Terms and Conditions. Amgen may use automatic dialing machines or artificial or prerecorded messages to contact me and may leave a voicemail or SMS/text message (standard text messaging rates may apply). 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. I understand Repatha can cause serious side effects including, serious allergic reactions. Repatha HMSA - 12/2021. XARELTO is indicated for the prophylaxis of DVT, which may lead to PE in adult patients undergoing knee or hip replacement surgery. 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. Appointment of Representative Form [PDF] Last Updated 10/01/2022 You'll send this form to the same place where you are sending your grievance, coverage determination, or appeal. Among the 16,676 patients without diabetes mellitus at baseline, the incidence of new-onset diabetes mellitus during the trial was 8.1% in patients treated with Repatha compared with 7.7% in patients that received placebo. 24 . provides a range of resources and information to help patients start and stay on track with treatment. Mobile Terms and Conditions. that the Maximum Monthly Benefit will not apply to the first three (3) Before starting Repatha, did you struggle to lower your bad cholesterol? Visit, in adults with cardiovascular disease to reduce the risk of heart attack, stroke, and certain types of heart. I understand that the operation and administration of certain of these services and/or programs may require that Amgen contact me by telephone or SMS/text. Follow the step-by-step instructions below to eSign your bausch patient assistance form: Select the document you want to sign and click Upload. For more information, call Dont see it in your inbox? 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. Card of your insurance carrier or Pharmacy Benefit Manager. By checking the I Agree box, I am electronically indicating that I have read and understood Amgens Patient Authorization (above in its full text), that I am legally authorized to consent and that I am 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 Patient Authorization. personal health information by only using and disclosing it as stated in the Authorization or as otherwise allowed or required by law. Registration for this program is closed at the moment. other patient support services. that my personal health information may include any information, in electronic or physical form, in the possession of or derived from a health care provider, health care plan, pharmacy, What is Repatha Patient Support Program? Contraindication: Repatha is contraindicated in patients with a history of a serious hypersensitivity reaction to evolocumab or any of the excipients in Repatha. I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by calling Amgen at 1-844-REPATHA (1-844-737-2842) or by writing to Amgen, PO Box 781046, Indianapolis, IN 46278-8046.. Page 2 of 7. Application just visit www.REPATHA.com or call repatha patient assistance form pdf ( 1-844-737-2842 ), Monday - Friday 8am - 9pm ET enrollment. Download our LDL Guide to keep track of your bad cholesterol number (measured mg/dL) as you go forward on Repatha. Please click to read the introduce you to the support they offer! satisfy the out-of-pocket cost-sharing requirement for any patient whose I authorize my Health Care Providers to disclose my personal health information to Amgen, and between themselves, as necessary, but only for the purposes stated above in this Authorization. information, for the following purposes only: To operate, administer, enroll me in, and/or continue my participation in Amgens By exiting the page, my activation and enrollment into RepathaReady will be discontinued. Decide on what kind of eSignature to create. RepathaReady offers resources and support services to help patients stay on track with their high LDL treatment. Dont see it in your inbox? You can count on us Now, more than 80%* of prescriptions for Repatha patients cost less than $50 per month * 89% of prescriptions cost patients less than $50 Discover the Repatha Copay Card 100% of prescriptions cost patients less than $50 with most patients paying less than $10 **RepathaReady Nurses are nurses by training. 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. Repatha Copay Card in order to be eligible for program With the Repatha Copay Card, a commercially insured patient who meets eligibility criteria may pay as little as a $5 copay per month for their Repatha monthly out-of-pocket costs. If you have questions regarding these terms and conditions or the Repatha Copay Card program, please call 1-844-REPATHA. If Yes, name of program or other source: Provide details and attach documentation of acceptance or decline: 1. Among the 16,676 patients without diabetes mellitus at baseline, the incidence of new-onset diabetes mellitus during the trial was 8.1% in patients treated with Repatha compared with 7.7% in patients that received placebo. Horsham, PA 19044-9979. Zioptan opthalmic solution (tafluprost) CONTACT INFO. Please answer the questions below to see if you are eligible for the Repatha Copay Card. When would you like your first refill reminder? other needs-based assistance provided by Amgen. limitations, please contact RepathaReady at 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. The guide below will help you find the insurance coverage most like yours. Be sure to bring the email or a copy of this page with you to the pharmacy. Repatha Sales Representatives are here to answer any for the cost of a Repatha prescription. 2021 Amgen Inc. All rights reserved. Phone: 800-736-0003 8am - 8pm EST Monday - Friday . Hypersensitivity reactions occurred in 5.1% and 4.7% of Repatha-treated and placebo-treated patients, respectively. 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. Please answer the following questions if you would like to schedule reminders as an additional tool to help you stay on track with Repatha. Reply HELP for As further described in the full terms and conditions, in general: Eligibility Criteria: Subject to program limitations and terms and conditions, the Repatha Copay Card is open to patients who have a Repatha prescription and who have commercial or private insurance, including plans available through state and federal healthcare exchanges. Form more information phone: 844-737-2842 or Visit website. Forms FAQs Provider Access Brochure Patient re-certification and authorization form. I understand that I am not Sign up to get important Repatha updates for your patients and your practice. To enroll in RepathaReady Reminders or receive subscription messages: Visit Repatha.com or call 1-844-737-2842. injection, and help you stay on track with treatment. call you within just a few days of signing up to If you do not have access to a fax machine, please mail documents to the Amgen Patient Assistance Program for Otezla at P.O. I understand that certain of my Health Care Providers (such as pharmacies and specialty pharmacies) may receive remuneration from Amgen in exchange for disclosing my 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 other patient support services. Conditions. Repatha via mobile phone text messages. RepathaReady offers resources and support services to help patients stay on track with their high LDL treatment. These programs are often referred to as copay maximizer programs. and provides support services. Box 5727, Louisville, Kentucky 40255-0727 Phone: 1-800-830-9159 Fax: 1-800-497-0928 CAN I APPLY? Patient Signature: Date 5 If applicable: Patient Authorization to Elect Representative for Purposes of Program Enrollment Patient Assistance Program Application Medicaid, TRICARE, Department of Defense, or Veteran Affairs programs), Contraindication: Repatha is contraindicated in patients with a history of a serious hypersensitivity reaction to evolocumab or any of the excipients in Repatha. If you have any questions or need further assistance, please call us at 1-844-REPATHA (1-844-737-2842). And your practice answer any for the prophylaxis of DVT, which may lead to PE in patients... 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