ENROLLMENT TIP SHEET FOR ON DEMAND PRODUCT FOR PATIENTS
Amgen Safety Net Foundation offers shipment in advance of administration for certain physician
administered medications. Under this model, providers complete a On Demand Product Request Form
after the patient has been enrolled to the Foundation. Amgen Safety Net Foundation ships On Demand
products directly to the provider in advance of administration.
Products available On Demand: Blincyto® (blinatumomab) for injection and IMLYGIC® (talimogene
laherparepvec).
Amgen Safety Net Foundation may be able to help
Amgen Safety Net Foundation is a nonprofit patient assistance program that helps qualifying uninsured
patients access Amgen medicines at no cost.
Do I qualify for help?
You may be able to receive Amgen medications at no cost from Amgen Safety Net Foundation if you
meet the following eligibility requirements:




Are a resident of the US or its territories
Satisfy income eligibility requirements
Have no or limited drug coverage
Do not have any other insurance or financial support options
If you have this many people in
household…
…your income must be at or below this
much each year
1
$60,300
2
$81,200
3
$102,100
4
$123,000
Each Additional Person
Add $20,900
To check if you qualify, you can:
 Go to www.amgensafetynetfoundation.com; or
 Call us at 1-888-762-6436
PO Box 18769
Louisville, KY 40261-7821
Effective February 2017
|
Phone: (888) 762-6436
Fax: (866) 549-7239
Revision ASNF Patient On Demand Application V12
|
www.amgensafetynetfoundation.com
Page 1 of 2
ENROLLMENT TIP SHEET FOR ON DEMAND PRODUCT FOR PATIENTS
How do I apply?
You will need to complete the patient information section of the application and sign the patient
certification and authorization to disclose information. Your provider is responsible for completing the
product, physician, and facility information, and for signing the facility certification. Either you or your
provider can submit the completed application.
Step 1: Get the Patient Application Form
 Go to www.amgensafetynetfoundation.com and click on the Forms tab; or
 Call us at 1-888-762-6436 and have the form faxed or mailed to you
Step 2: Complete pages 1, 2, 3 of the Patient Application Form for Physician Administered Products
 Fill in the Patient Information (pages 1 and 2 of the application)
 If you are unsure how to fill out any part of this form, you may be able to get assistance from
your provider or you can call us at 1-888-762-6436 to speak to one of our agents
Step 3: Sign and date the Patient Certification and Authorization (page 3 of the application)
Step 4: Your provider must complete the product, physician, and facility information and sign the
facility certification (page 4 of the application)
Step 5: Either you or your provider can submit the completed Patient Application Form for Physician
Administered Products
 Review the application and make sure all of the required information has been filled in to avoid
any processing delays
 Fax the form to 1-866-549-7239 or mail to: Amgen Safety Net Foundation, PO Box 18769,
Louisville, KY, 40261-7821
When will I find out if I’m approved?
Once a completed application and any requested supporting documents have been received and
processed, you and provider will be notifed of the enrollment decision. Missing information or an
incomplete application will delay an enrollment decision.
How do I receive product?
You will receive your medication from your provider.
If you have any 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 speak 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
Effective February 2017
|
Phone: (888) 762-6436
Fax: (866) 549-7239
Revision ASNF Patient On Demand Application V12
|
www.amgensafetynetfoundation.com
Page 2 of 2