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Click if you use Pushtronex ^® system (on-body infusor with prefilled cartridge) and need support

Get Helpful Resources With Amgen^® SupportPlus

Whether you’re taking Repatha^® or considering asking your doctor about a prescription, Amgen^® provides helpful resources to support you on your path to lowering high bad cholesterol (LDL-C). For Repatha^® patients, Amgen SupportPlus offers additional support including the Repatha^® Co-Pay Card for eligible commercially insured patients.*

*Eligibility criteria and program maximums apply. See www.repatha.com/copaytcs for full Terms and Conditions.

Do you have a Repatha^® prescription?

Yes, I have a Repatha^® prescription

No, I do not have a Repatha^® prescription

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Program Enrollment –
Patient Information

*First Name

*Last Name

*Zip Code

*Date of Birth

*Email

*Sex at Birth

Mobile Phone

Step 1 Of 2

*Please make a selection

Consent to Health Data Collection & Processing for Marketing Purposes

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

To conduct marketing activities, including market research activities, and to communicate with me regarding products and services that may be of interest to me.

Amgen uses the following for marketing purposes:

Health Data – my name, gender, date of birth, contact information and information relating to my health condition or treatment.

I understand that Amgen is seeking my consent to collect and process my Health Data to market products and services to me and that I do not have to give consent to the collection and processing of my Health Data for marketing purposes. I also understand that Amgen will not sell my Health Data to third parties. If I consent to the collection and processing of my Health Data for marketing purposes, I agree that Amgen may contact me for marketing purposes. Finally, I understand that I may withdraw my consent to the collection and processing of my Health Data for marketing purposes at any time using the method listed in the Additional Disclosures section below.

I consent to the collection and processing of my Health Data for marketing purposes I do not consent to the collection and processing of my Health Data for marketing purposes If you do not consent to the collection and processing of your health data for marketing purposes, you will not be able to receive marketing communications from Amgen. If you want to receive marketing communications from Amgen, select “I consent to the collection and processing of my Health Data for marketing purposes” If you do not consent to the collection and processing of your health data for marketing purposes, you will not be able to receive marketing communications from Amgen. If you want to receive marketing communications from Amgen, select “I consent to the collection and processing of my Health Data for marketing purposes”

Step 2 Of 2

*Please make a selection

Consent to Health Data Disclosure for Marketing Purposes

I consent to Amgen disclosing my Health Data to its data processors, contractors, and business partners for the following purposes:

To conduct marketing activities, including market research activities, and to communicate with me regarding products and services that may be of interest to me.

If I provide my consent, Amgen will disclose the following for such purposes:

Health Data – my name, gender, date of birth, contact information and information relating to my health condition or treatment.

I understand that Amgen is seeking my consent to disclose my Health Data to its data processors, contractors, and business partners to market products and services to me and that I do not have to give consent to disclosure of my Health Data for marketing purposes. I also understand that Amgen will not sell my Health Data to third parties. Finally, I understand that I may withdraw my consent to the disclosure of my Health Data for marketing purposes at any time using the method listed in the Additional Disclosures section below.

I consent to the disclosure of my Health Data for marketing purposes I do not consent to the disclosure of my Health Data for marketing purposes If you do not consent to the disclosure of your health data for marketing purposes, you will not be able to receive marketing communications from Amgen. If you want to receive marketing communications from Amgen, select “I consent to the disclosure of my Health Data for marketing purposes” If you do not consent to the disclosure of your health data for marketing purposes, you will not be able to receive marketing communications from Amgen. If you want to receive marketing communications from Amgen, select “I consent to the disclosure of my Health Data for marketing purposes”

Additional Disclosures

I understand that 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 contact Amgen by visiting www.amgen.com/DataSubjectRights. For more information about Amgen’s privacy practices, Amgen’s Privacy Statement can be found at http://www.amgen.com/privacy.

Program Enrollment – Patient Information

*First Name

*Last Name

*Address Line 1

Address Line 2

*City

*State

*ZIP Code

*Date of Birth

Alternate address found. Please select one

Entered Address:

Suggested Address:

*Email

*Mobile Phone

*Sex at Birth

Healthcare Representative (Complete, if applicable)

I am a healthcare representative assisting a patient with enrollment.

Patient Authorization and Consents

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Based on your responses, you are eligible for the Repatha Co-Pay Card. To complete your enrollment, please read the full terms and conditions below and check the box to indicate your agreement.

REPATHA^® (evolocumab)
CO-PAY CARD
TERMS & CONDITIONS

SUMMARY OF TERMS AND CONDITIONS

It is important that every patient read and understand the full Repatha^® (evolocumab) Co-pay Card Terms and Conditions. The following summary is not a substitute for reviewing the Terms and Conditions in their entirety.

As further described below, in general:

The Repatha^® Co-pay Card is open to patients with commercial insurance, regardless of financial need. The program is not valid for patients whose Repatha^® prescription 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 below.)
With the Repatha^® Co-pay Card, a commercially insured patient who meets eligibility criteria may pay as little as a $5 co-pay per month for their Repatha^® monthly out-of-pocket costs. Monthly out-of-pocket costs include co-payment, co-insurance, and deductible out-of-pocket costs. Amgen will pay the remaining eligible out-of-pocket costs on behalf of the patient up to a Maximum Monthly Benefit, a Maximum Annual Program Benefit and/or the Patient Total Program Benefit. Patients are responsible for all amounts that exceed these limits. (See PROGRAM DETAILS section below.)
Offer is subject to change or discontinuation without notice.
The Repatha^® Co-pay Card provides support up to the Maximum Monthly Benefit, the Maximum Annual Program Benefit and/or Patient Total Program Benefit. If a patient’s commercial insurance plan imposes different or additional requirements on patients who receive Repatha^® Co-pay Card benefits, Amgen has the right to modify or eliminate those benefits. Whether you are eligible to receive the Maximum Monthly Benefit, 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 Repatha^® Co-pay Card, and whether your particular insurance coverage is likely to result in your reaching the Maximum Monthly Benefit, the Maximum Annual Program Benefit, or your Patient Total Program Benefit, by calling 1-844-REPATHA (1-844-737-2842). (See PROGRAM BENEFITS section below.)

ELIGIBILITY

Eligibility Criteria: Subject to program limitations and terms and conditions, the Repatha^® Co-pay 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. This program helps eligible patients cover out-of-pocket costs related to Repatha^®, up to program limits. There is no income requirement to participate in this program.

This offer is not valid for patients whose Repatha^® prescription 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 Repatha^® 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 a Repatha^® prescription. This offer is only valid in the United States, Puerto Rico, and the US territories.

PROGRAM BENEFITS

The Repatha^® Co-pay Card helps provide out-of-pocket support to eligible patients for their Repatha^® prescription up to program limits. See PROGRAM DETAILS for full description.

The Repatha^® Co-pay Card offer does not cover out-of-pocket costs for any patient whose selected coverage option under their commercial insurance plan does not apply Repatha^® Co-pay Card payments to satisfy the patient’s co-payment, deductible, or co-insurance for Repatha^®. Patients with these plan limitations are not eligible for the Repatha^® Co-pay Card but may be eligible for other needs-based assistance provided by Amgen. These programs are often referred to as accumulator adjustment programs. If you believe your commercial insurance plan may have such limitations, please contact Amgen SupportPlus at 1-844-REPATHA (1-844-737-2842).

The Repatha^® 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 Repatha^® 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 at 1-844-REPATHA (1-844-737-2842). Health plans and Pharmacy Benefit Managers are prohibited from enrolling or assisting in the enrollment of patients in the Repatha^® Co-pay Card. The patient, or his/her legal representative, must personally enroll in the Repatha^® Co-pay Card in order to be eligible for program benefits.

If at any time a patient begins receiving prescription drug coverage 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 they must contact Amgen SupportPlus at 1-844-REPATHA (1-844-737-2842) to stop their participation in this program.

Patients may not seek reimbursement for the value received from the Repatha^® 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 Repatha^® Co-pay Card of your insurance carrier or Pharmacy Benefit Manager. Restrictions may apply. Offer is subject to change or discontinuation without notice. This is not health insurance.

PROGRAM DETAILS

With the Repatha^® Co-pay Card, a commercially insured patient who meets eligibility criteria may pay as little as a $5 Co-pay per month for their Repatha^® monthly out-of-pocket costs.

For all eligible patients, the Repatha^® Co-pay Card offers:

A program benefit that covers the patient’s eligible out-of-pocket prescription costs for Repatha^® (co-pay, deductible, or co-insurance) on behalf of the patient, up to a Maximum Monthly Benefit and/or a Maximum Annual Program Benefit.
Repatha^® patients may pay $5 out of pocket at the first fill and at every refill, and Amgen will pay on behalf of the patient the remaining eligible out-of-pocket prescription costs (up to the Patient Total Program Benefit described below; Repatha^® patients are responsible for all amounts that exceed this limit).

Maximum Monthly Benefit, Maximum Annual Program Benefit, and/or Patient Total Program Benefit and Benefits May Change, End, or Vary without notice.
The Maximum Annual Program Benefit must be applied to the Repatha^® patient’s out-of-pocket costs (co-pay, deductible, or co-insurance).
The Patient Total Program Benefit amounts are unilaterally determined by Amgen in its sole discretion and will not exceed the Maximum Monthly Benefit or Maximum Annual Program Benefit. The Patient Total Program Benefit may be less than the Maximum Monthly Benefit or Maximum Annual Program Benefit, depending on the terms of a patient’s prescription drug 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 Representative to help you understand whether your particular insurance coverage is likely to result in your reaching the Maximum Monthly Benefit, Maximum Annual Program Benefit or your Patient Total Program Benefit amount by calling 1-844-REPATHA (1-844-737-2842) and follow the prompts.
Participating patients are solely responsible for updating Amgen with changes to their prescription health insurance including, but not limited to, initiation of insurance provided by the government, the addition of any coverage terms that do not apply Repatha^® 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 fill their Repatha^® prescription. Benefits reset each calendar year. Re-enrollment in the program is required at regular intervals. Patients may continue in the program as long as the 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/re-enroll by calling 1-844-REPATHA (1-844-737-2842) or by going to Repatha.com/copay.

By checking this box, I agree that I have read and understand the Terms and Conditions of the Repatha Co-Pay Card

Congratulations—You Are Now Enrolled in Amgen^® SupportPlus!

You will also be receiving:

Congratulations—You Are Now Enrolled in Amgen^® SupportPlus!

You will be receiving:

Congratulations—You Are Now Enrolled in Amgen^® SupportPlus!

We’re right here, right when you need us.

USE YOUR REPATHA^® CO-PAY CARD TODAY TO PAY AS LITTLE AS $5 PER MONTH*

To use your co-pay card, follow these 3 simple steps

Print

This is your personal co-pay card information:

RxBin: [XXXXX]

RxPCN: [XXXXX]

RxGrp: [XXXXX]

ID: [XXXXX]

Print

If you have any questions, please contact 1-844-REPATHA (1-844-737-2842).

*Eligibility criteria and program maximums apply. See full Terms and conditions.

Over the coming weeks, you’ll receive personalized emails to help you navigate your Repatha^® journey.

Here are the additional services you have requested.

*Amgen^® Nurse Partners are only available to patients that are prescribed certain Amgen products. They are not part of your patient’s 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.