SupportPlus Enrollment | AMJEVITA® (adalimumab-atto)

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Patient Date of Birth

Patient Authorization and Consents

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Authorization for Use and Disclosure of Protected Health Information

AMJEVITA^® is distributed by both Amgen and Nuvaila^TM. Amgen operates Amgen SupportPlus both on its own behalf and on behalf of Nuvaila^TM.

Uses and Disclosure of Protected Health Information

I authorize Amgen, Nuvaila, and their data processors (collectively, “Amgen and Nuvaila”) to collect, use, and disclose my protected health information for the following purposes:

To operate, administer, enroll me in, and/or continue my participation in Amgen SupportPlus program or any other Amgen- or Nuvaila-affiliated patient support services and activities related to my condition or treatment (for example, co-pay card programs, reimbursement assistance programs, drug coverage verification, nurse partner services, adherence program and disease management support);
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;

and/or

To improve, develop, and evaluate Amgen’s and Nuvaila’s products, services, materials and programs related to my condition or treatment.

In order for Amgen and Nuvaila to provide me with the services and/or programs described above, Amgen and Nuvaila need to collect and use my personal information, including my protected health information. I understand that my protected 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, pharmaceutical company, laboratory and/or their contractor (each, a “Health Care Provider”). This may include select information from or about my medical history and general health, my health care plan benefits, payment limits or restrictions covered by my health care plan policy, and/or my adherence to my treatment.

I authorize my Health Care Providers to disclose my protected health information to Amgen and Nuvaila, and between themselves, as necessary, but only for the purposes stated above in this Authorization. I understand that certain of my Health Care Providers (such as pharmacies and specialty pharmacies) may receive remuneration from Amgen and Nuvaila in exchange for disclosing my protected health information and/or for using my information to contact me with communications about Amgen and Nuvaila products which have been prescribed to me (for example, medication reminder programs and other patient support services).

Expiration, Right to Obtain a Copy, and Right to Cancel

I understand that by signing this form, I authorize my Health Care Providers or others who might hold my health information to disclose it to Amgen and Nuvaila. I also understand I am authorizing my personal information, including my protected health information, to be used for the purposes described above. I understand and agree that by signing below, I am authorizing those who rely on this Authorization to disclose my protected health information for the earlier of five (5) years or until my participation in Amgen SupportPlus ends through my cancellation, unless a shorter time period is required by state law.

I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by calling Amgen and Nuvaila at 1-888-8AMJEVITA (1-888-826-5384) or by writing to PO BOX 2135, Morristown, NJ 07962-9927. If I cancel this Authorization, I will no longer qualify for the services described. I also understand that if a Health Care Provider is disclosing my protected health information to Amgen and Nuvaila in reliance on this Authorization on an on-going basis, my cancellation with Amgen and Nuvaila will be effective with respect to any such Health Care Providers as soon as they receive notice of my cancellation.

No Effect on Treatment

I understand I do not have to sign this Authorization and that my enrollment in any of the services and/or programs described above is entirely voluntary. I understand that Amgen and Nuvaila, as well as Health Care Providers, cannot require me, as a condition of having access to medications, prescription drugs, treatment or other care, to sign this Authorization. Federal Law (including HIPAA) requires a signed authorization in order for Amgen and Nuvaila to collect my protected health information from my Health Care Providers. I understand I cannot participate in the listed services and/or programs without signing this Authorization or an equivalent authorization with my Health Care Providers.

Information Received from Health Care Providers

I understand that once my protected health information has been disclosed to Amgen and Nuvaila, federal privacy laws may no longer apply and may no longer protect it from further disclosure, and that Amgen and Nuvaila may disclose my protected health information to their data processors, contractors, and business partners for their business purposes. Amgen and Nuvaila agree, however, to protect my protected health information by only using and disclosing it as stated in the Authorization or as otherwise allowed or required by law.

By clicking the “I consent” button, I am electronically indicating that I have read and understood the above Authorization for Use and Disclosure of Protected Health Information (above in its full text), that I am legally authorized to consent, and that I am providing my consent as the patient or the patient’s legal representative for Amgen and Nuvaila to collect, use, and disclose my protected health information for the purposes described within this Authorization. By clicking “I do not consent” below, my activation and enrollment into Amgen SupportPlus will be discontinued.

I consent I do not consent By selecting "I do not consent," you will not be able to continue enrolling in Amgen SupportPlus By selecting "I do not consent," you will not be able to continue enrolling in Amgen SupportPlus

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Consent to Health Data Processing for Amgen SupportPlus

AMJEVITA^® is distributed by both Amgen and Nuvaila^TM. Amgen operates Amgen SupportPlus both on its own behalf and on behalf of Nuvaila^TM.

I consent to Amgen and Nuvaila processing my Health Data for the following purposes:

To enroll me and manage my participation in Amgen SupportPlus program, which includes activities related to my condition or treatment (for example, co-pay card programs, payer medication coverage verification, nurse partner support, disease management support), and to manage Amgen’s and Nuvaila’s products, services, and programs related to my condition or treatment.

Amgen and Nuvaila use the following when it administers the Amgen SupportPlus program:

Health Data – my name (and the name of my caregiver if applicable), gender, date of birth, contact information and information relating to my health condition or treatment.

I understand that my consent to processing is required for me to participate in the Amgen SupportPlus program. I also understand that Amgen and Nuvaila will not sell my Health Data to third parties, but Amgen and Nuvaila may disclose my Health Data to Amgen’s and Nuvaila’s data processors, contractors, and business partners for Amgen’s and Nuvaila’s business purposes related to the Amgen SupportPlus program. I understand that Amgen and Nuvaila may use my Health Data to contact me by mail, email, telephone or text for the above purposes. I also understand that if I do not consent to the use of my Health Data for the above purposes, I will not be able to participate in the Amgen SupportPlus program. Finally, I understand that I may withdraw my consent to processing my Health Data for the above purposes at any time using one of the methods listed in the Additional Disclosures section below and that if I withdraw my consent, I will no longer be able to participate in the Amgen SupportPlus program.

I consent to the collection, processing, and disclosure of my Health Data for the above purposes I do not consent to the collection, processing, or disclosure of my Health Data for the above purposes By selecting “I do not consent to the collection, processing, or disclosure of my Health Data for the above purposes,” you will not be able to continue enrolling in Amgen SupportPlus By selecting “I do not consent to the collection, processing, or disclosure of my Health Data for the above purposes,” you will not be able to continue enrolling in Amgen SupportPlus

Additional Disclosures

I understand that participation in the Amgen SupportPlus program and, if I have consented, receipt of marketing communications are optional services at no cost to me. The consent(s) above in no way affects my right to obtain any medications and I do not have to provide consent to be able to receive any medications. To obtain a copy of the consent(s) above or to withdraw my consent to collection, processing, and/or disclosure of my Health Data for any of the above purposes to which I have consented, I can visit www.amgen.com/DataSubjectRights or call Amgen at 1-888-8AMJEVITA (1-888-826-5384). For more information about Amgen’s and Nuvaila’s privacy practices, Amgen’s and Nuvaila’s Privacy Statements can be found at www.nuvaila.com/privacy and www.nuvaila.com/privacy, respectively.

Have questions about injecting for AMJEVITA?

For patients looking for one-on-one support, Amgen^® Nurse Partners* are here to help. Amgen Nurse Partners can provide supplemental injection support at no cost to you as an AMJEVITA patient. If you would like to connect with an an Amgen Nurse Partner please call 1-888-8AMJEVITA (1-888-826-5384) Monday - Friday, 8 AM - 8 PM ET.

Amgen Nurse Partners provide support to all patients taking AMJEVITA, regardless of distributor.

*Amgen Nurse Partners are only available to patients that are prescribed certain Amgen products. They are not part of your treatment team and do not provide medical advice, nursing, or case management services. Amgen Nurse Partners will not inject patients with Amgen medications. Patients should always consult their healthcare provider regarding medical decisions or treatment concerns.

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SUMMARY OF TERMS AND CONDITIONS

It is important that every patient read and understand the full Amgen^® SupportPlus Co-Pay Card Terms and Conditions. The following summary is not a substitute for reviewing the Terms and Conditions in their entirety. Please visit www.AmgenSupportPlus.com for full Terms and Conditions.

The Amgen SupportPlus Co-Pay Card is open to patients with commercial insurance that covers an Amgen SupportPlus product, regardless of financial need. The program is not valid for patients whose prescription for an Amgen SupportPlus product is paid for in whole or in part by Medicare, Medicaid, or any other federal or state healthcare program. It is not valid for cash paying patients or where prohibited by law. (See ELIGIBILITY section in full Terms & Conditions.)
The Amgen SupportPlus Co-Pay Card may help lower your Amgen SupportPlus product out-of-pocket medication costs. Out-of-pocket costs may include co-payment, co-insurance, and deductible out-of-pocket costs. The Amgen SupportPlus Co-Pay Card does not cover any other costs related to office visits or administration of the product. The Amgen SupportPlus Co-Pay Card provides support up to the Maximum Program Benefit or Patient Total Program Benefit. If a patient's commercial insurance plan imposes different or additional requirements on patients who receive Amgen SupportPlus Co-Pay Card benefits, Amgen has the right to modify or eliminate those benefits. Whether you are eligible to receive the Maximum Program Benefit or Patient Total Program Benefit is determined by the type of plan coverage you have. Please ask your Amgen SupportPlus Representative to help you understand eligibility for the Amgen SupportPlus Co-Pay Card, whether your particular insurance coverage is likely to result in your reaching the Maximum Program Benefit or your Patient Total Program Benefit amount by calling 1-833-44AMGEN (1-833-442-6436). (See PROGRAM BENEFITS section in full Terms & Conditions.)
Amgen SupportPlus patient may pay as little as $0 out-of-pocket for each prescription fill, dose or cycle of the Amgen SupportPlus product
Amgen will pay the remaining eligible out-of-pocket costs on behalf of the patient until the Amgen payments have reached either the Maximum Program Benefit and/or the Patient Total Program Benefit. Patients are responsible for all amounts that exceed this limit. Please ask your Amgen SupportPlus Support Representative to help you understand eligibility for the Amgen SupportPlus Co-Pay Card by calling 1-833-44AMGEN (1-833-442-6436). (See PROGRAM DETAILS section in full Terms & Conditions.)

For Otezla^® (apremilast) patients only:

Bridge to Commercial Coverage Offer: If the patient's health plan requires a prior authorization or if patient experiences a delay in obtaining approval for Otezla^® (apremilast), the patient can receive Otezla free for up to twelve (12) prescription fills within twelve (12) months from the date of the first prescription filled under the Bridge to Commercial Coverage Offer while pursuing approval from patient's health plan. No purchase necessary. Once Otezla is approved by the patient's health plan, the patient is no longer eligible for the Bridge to Commercial Coverage Offer.

Ongoing eligibility after the first three (3) fills requires that the patient has a prior authorization or medical exception denied within ninety (90) days of first use of this offer. Once insurance approval is obtained, patient is no longer eligible for this offer.
This is a one-time offer and patients are ineligible to re-enroll.

I. ELIGIBILITY

*Eligibility Criteria: Subject to program limitations and terms and conditions, the Amgen SupportPlus Co-Pay Card is open to patients who have been prescribed an Amgen SupportPlus product and who have commercial or private insurance that covers an Amgen SupportPlus product, including state and federal plans commonly referred to as “healthcare exchanges plans”. This program helps eligible patients cover out-of-pocket medication costs related to an Amgen SupportPlus product, up to program limits. The Amgen SupportPlus Co-Pay Card does not cover any other costs related to office visits or administration of an Amgen SupportPlus product. There is no income requirement to participate in this program.

This offer is not valid for patients whose prescription for an Amgen SupportPlus product is paid for in whole or in part by Medicare, Medicaid, or any other federal or state healthcare program. It is not valid for cash-paying patients or where prohibited by law. A patient is considered cash-paying where the patient has no insurance coverage for an Amgen SupportPlus product or where the patient has commercial or private insurance but Amgen in its sole discretion determines the patient is effectively uninsured because such coverage does not provide a material level of financial assistance for the cost of an Amgen SupportPlus product prescription. This offer is only valid in the United States, Puerto Rico, and the US territories.

For Otezla^® (apremilast) patients only:

II. PROGRAM BENEFITS

The Amgen SupportPlus Co-Pay Card may modify the 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 Amgen SupportPlus Co-Pay Card as a condition of the plan or PBM waiving some or all of an otherwise applicable patient out-of-pocket cost sharing amount. These programs are often referred to as co-pay maximizer programs. If you believe your commercial insurance plan may have such limitations, please contact Amgen SupportPlus Support at 1-833-44AMGEN (1-833-442-6436). Health plans and Pharmacy Benefit Managers are prohibited from enrolling or assisting in the enrollment of patients in the Amgen SupportPlus Co-Pay Card. The patient, or his/her legal representative, must personally enroll in the Amgen SupportPlus Co-Pay Card in order to be eligible for program benefits.

If at any time a patient begins receiving coverage for medications under any federal, state, or government healthcare 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 you must contact Amgen SupportPlus at 1-833-44AMGEN (1-833-442-6436) (Monday through Friday, from 8:00 am to 8:00 pm ET) to stop your participation in this program.

Patients may not seek reimbursement for the value received from the Amgen SupportPlus Co-Pay Card from any third-party payers, including a flexible spending account or healthcare savings account. Participating in this program means that you are ensuring you comply with any required disclosure regarding your participation in the Amgen SupportPlus Co-Pay Card of your insurance carrier or pharmacy benefit manager. Restrictions may apply. Offer subject to change or discontinuation without notice. This is not health insurance.

III. PROGRAM DETAILS

For all eligible patients the Amgen SupportPlus Co-Pay Card offers:

A program benefit that covers the patient's eligible out-of-pocket medication costs for the Amgen SupportPlus product (co-pay, deductible, or co-insurance) on behalf of the patient, up to a Maximum Program Benefit determined by the program per calendar year. The Amgen SupportPlus Co-Pay Card does not cover any other costs related to office visits or administration of an Amgen SupportPlus product.
Amgen SupportPlus patients may pay as little as $0 out-of-pocket for each prescription fill, dose or cycle.
Amgen will pay the remaining eligible out-of-pocket prescription costs on behalf of the patient until the Amgen payments have reached either the Maximum Program Benefit and/or the Patient Total Program Benefit. Patients are responsible for all amounts that exceed this limit.

For Otezla^® (apremilast) patients only:

Bridge to Commercial Coverage Offer: If the patient's health plan requires a prior authorization or if patient experiences a delay in obtaining approval for Otezla^® (apremilast), the patient can receive Otezla free for up to twelve (12) prescription fills within twelve (12) months from the date of the first prescription filled under the Bridge to Commercial Coverage Offer while pursuing approval from patient's health plan. No purchase necessary. Once Otezla is approved by the patient's health plan, the patient is no longer eligible for the Bridge to Commercial Coverage Offer.

Ongoing eligibility after the first three (3) fills requires that the patient has a prior authorization or medical exception denied within ninety (90) days of first use of this offer. Once insurance approval is obtained, patient is no longer eligible for this offer.
This is a one-time offer and patients are ineligible to re-enroll.

Maximum Program Benefit, Patient Total Program Benefit, Benefits May Change, End or Vary Without Notice: The program provides up to a Maximum Program Benefit of support to reduce a patient's out-of-pocket medication costs that Amgen will provide per patient for each calendar year, which must be applied to the Amgen SupportPlus patient's out-of-pocket costs (co-pay, deductible, or co-insurance and annual out-of-pocket maximum). Patient Total Program Benefit amounts are unilaterally determined by Amgen in its sole discretion and will not exceed the Maximum Program Benefit. The Patient Total Program Benefit may be less than the Maximum Program Benefit, depending on the terms of a patient's plan, and may vary among individual patients covered by different plans, based on factors determined solely by Amgen, to ensure all programs funds are used for the benefit of the patient. Each patient is responsible for costs above the Patient Total Program Benefit amounts. Please ask your Amgen SupportPlus Support Representative to help you understand whether your particular insurance coverage is likely to result in your reaching the Maximum Program Benefit or your Patient Total Program Benefit amount by calling 1-833-44AMGEN (1-833-442-6436). Participating patients are solely responsible for updating Amgen with changes to their insurance including, but not limited to, initiation of insurance provided by the government, the addition of any coverage terms that do not apply Amgen SupportPlus Co-Pay Card benefits to reduce a patient's out-of-pocket costs, such as accumulator adjustment benefit design or a co-pay maximization program. Participating patients are responsible for providing Amgen with accurate information necessary to determine program eligibility. By accepting payments from Amgen made on behalf of participating patients, participating PBMs and Plans likewise are responsible for providing Amgen with accurate information regarding patient eligibility. The program provides up to a Maximum Program Benefit of support to reduce a patient's out-of-pocket medication costs that Amgen will provide per patient for each calendar year, which must be applied to the Amgen SupportPlus patient's out-of-pocket costs (co-pay, deductible, or co-insurance and annual out-of-pocket maximum). Patient Total Program Benefit amounts are unilaterally determined by Amgen in its sole discretion and will not exceed the Maximum Program Benefit. The Patient Total Program Benefit may be less than the Maximum Program Benefit, depending on the terms of a patient's plan, and may vary among individual patients covered by different plans, based on factors determined solely by Amgen, to ensure all programs funds are used for the benefit of the patient. Each patient is responsible for costs above the Patient Total Program Benefit amounts. Please ask your Amgen SupportPlus Support Representative to help you understand whether your particular insurance coverage is likely to result in your reaching the Maximum Program Benefit or your Patient Total Program Benefit amount by calling 1-833-44AMGEN (1-833-442-6436). Participating patients are solely responsible for updating Amgen with changes to their insurance including, but not limited to, initiation of insurance provided by the government, the addition of any coverage terms that do not apply Amgen SupportPlus Co-Pay Card benefits to reduce a patient's out-of-pocket costs, such as accumulator adjustment benefit design or a co-pay maximization program. Participating patients are responsible for providing Amgen with accurate information necessary to determine program eligibility. By accepting payments from Amgen made on behalf of participating patients, participating PBMs and Plans likewise are responsible for providing Amgen with accurate information regarding patient eligibility.

Patients may use the card every time they receive a prescription fill, dose or cycle of the Amgen SupportPlus product, up to the Maximum Program Benefit or Patient Total Program Benefit. Benefits reset each calendar year. Re-enrollment in the program is required at regular intervals. Patients may continue in the program as long as patient re-enrolls as required by Amgen and continues to meet all of the program’s eligibility requirements during participation in the program. Patients can enroll/reenroll by calling 1-833-44AMGEN (1-833-442-6436).

INDICATIONS

Patient Date of Birth

Insurance Information

COMMERCIAL INSURANCE

GOVERNMENT-PROVIDED

I DON'T HAVE INSURANCE

Are you eligible for Medicare but receive prescription drug coverage from a former employer, union, or welfare plan?

Patient Information

Healthcare Representative (Complete, if applicable)

Patient Authorization and Consents

Step 1 Of 2

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Step 2 Of 2

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Additional Disclosures

Have questions about injecting for AMJEVITA?

You are now enrolled. Congratulations!

Add us to your contacts

We’re sorry, but an error has occurred.

Already have a prescription? Enroll in the AMJEVITA® Co-﻿Pay Program*

Patient Date of Birth

Insurance Information

COMMERCIAL INSURANCE

GOVERNMENT-PROVIDED

I DON'T HAVE INSURANCE

Are you eligible for Medicare but receive prescription drug coverage from a former employer, union, or welfare plan?

Patient Information

Healthcare Representative (Complete, if applicable)

Patient Authorization and Consents

Step 1 Of 2

*Please make a selection

Step 2 Of 2

*Please make a selection

Additional Disclosures

Have questions about injecting for AMJEVITA?

SUMMARY OF TERMS AND CONDITIONS

You are now enrolled. Congratulations!

AMJEVITA Co-Pay Card

Add us to your contacts

We’re sorry, but an error has occurred.

Already have a prescription?
Enroll in the AMJEVITA^® Co-Pay Program*