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| Drug Information | ||||||||||
| Drug | Neulasta | |||||||||
| Generic Equivalent | pegfilgrastim | |||||||||
| Class | White Cell Booster | |||||||||
| Topic | Cancer | |||||||||
| Program Contact Info / Application Submission | ||||||||||
| Program | Safety Net Program | |||||||||
| Company | Amgen | |||||||||
| Address | PO Box 13185, La Jolla, CA 92039 | |||||||||
| Phone | 888-762-6436 | |||||||||
| Fax | 877-727-2867 | |||||||||
| Website | http://www.reimbursementconnection.com/neulasta/other_programs/other_programs_services.jsp#safetynet_program | |||||||||
| Program Details | ||||||||||
| Details | Up to a 30-day supply is shipped to the doctor's office. A refill/reorder form is included with each shipment, which must be filled out and returned in order to get the next shipment. A new application and documentation is needed once a year. | |||||||||
| Program Requirements | ||||||||||
| Information | The doctor must fill out their section and sign the application. The patient must also fill out their section and sign the application. | |||||||||
| Details | Insurance card NOT required Drivers license NOT required Proof of Income NOT required | |||||||||
| Delivery of Medication | ||||||||||
| Ship Time | within 30 days | |||||||||
| Delivery Options | Can be delivered directly to the patient Can NOT be delivered directly to the doctor Shipped as a voucher card | |||||||||
| Application Process | ||||||||||
| App Process | The doctor or doctor's office can call and request an application. Applications are faxed out. Completed applications can either be faxed or mailed back. The doctor is notified of acceptance or denial and medication is usually shipped within 30 days of acceptance. | |||||||||
| New Applications | New applications NOT accepted Patients can NOT apply directly to the program Doctors can NOT apply directly to the program Advocates can NOT apply directly to the program Can apply for a new application via phone Can NOT apply for a new application via fax Can NOT apply for a new application via mail | |||||||||
| Refills | Refills NOT accepted Patients can apply for refills Doctors can NOT apply for refills Advocates can apply for refills Can apply for refills via phone Can NOT apply for refills via fax Can NOT apply for refills via mail | |||||||||
| Re-Applications | Re-Applications NOT accepted Patients can NOT apply for Re-Applications Doctors can NOT apply for Re-Applications Advocates can NOT apply for Re-Applications Can Re-Apply via phone Can NOT Re-Apply via fax Can NOT Re-Apply via mail | |||||||||
| Appeals | Income Appeals NOT accepted Patients can NOT apply for Income Appeals Doctors can NOT apply for Income Appeals Advocates can NOT apply for Income Appeals Hardship Appeals NOT accepted Patients can NOT apply for Hardship Appeals Doctors can NOT apply for Hardship Appeals Advocates can NOT apply for Hardship Appeals Can apply for an appeal via phone Can NOT apply for an appeal via fax Can NOT apply for an appeal via mail | |||||||||
| Eligibility | ||||||||||
| Eligibility | This program is based on income guidelines which are not disclosed. As this is a replacement program, Form C can only be sent in after the patient has been prescribed and used the medication being requested. Providers must be sponsors for patients in order for them to be enrolled into this program. After a provider has filled out a Sponsor Form (Form A) for any patient, the provider does not have to fill out another form for additional patients. Epogen is for dialysis patients only. If any patient is Medicare Part D eligible, then they do not qualify for this program. Regardless of the patient�s income or insurance status, once their out-of-pocket expenses for Vectibix exceed 5% of their household adjusted gross income; they may enroll into this program. | |||||||||
| Limitations | Patients are eligible if LIS is denied Patients are eligible with existing prescription coverage Patients are eligible if prescription is not covered Patients are eligible if prescription coverage has been exhausted Patients are eligible if they are accepting Medicare Patients are eligible if they are accepting Medicare part D Patients are eligible if the medication is not covered under Medicare Patients are eligible if Medicare coverage has been exhausted | |||||||||
| Appeals | ||||||||||
| Conditions | Appeals will NOT consider out-of-pocket expenses Appeals will NOT consider total medical expenses Appeals may be made before the patient has been denied on a case by case basis | |||||||||
| Other Medications | ||||||||||
| Other Medications available in this program |
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