INSURANCE VERIFICATION AND
PRIOR AUTHORIZATION FORM
Please fill in the following 2 pages if you are a healthcare provider requesting insurance verification.
PATIENT INFORMATION
First Name MI Last Name
Street Address City State ZIP
Phone Number Date of Birth / / Gender F M
Alternate Contact /Caregiver Information
First Name Last Name Phone Number
Relationship to Patient
Do you have the patient’s consent for the program to contact the caregiver? Yes No
Patient Primary Insurance Information Patient Secondary Insurance Information
For LUMAKRAS™ (sotorasib), please provide Patient Pharmacy Insurance Information
Insurance Name Insurance Name
Policy # Policy #
Policy Holder Name Policy Holder Name
Date of Birth Date of Birth
Relation to Patient Relation to Patient
Insurance Phone # Insurance Phone #
Group # Group #
PRESCRIBER INFORMATION
Prescriber Name State Where Licensed State License #
NPI # Tax ID #
Physician Name
(if different from the prescriber) State Where Licensed State License #
Payer Specific Provider Number
Prescriber Hospital Hospital
Facility Name Facility NPI # Facility Type Office/Clinic Outpatient Inpatient
Facility Address City State ZIP
Primary Contact Name Title/Role
Primary Phone # Primary Fax # Primary Email
By completing and faxing this form, you represent that your patient is aware of the disclosure of their personal health information
to Amgen and its agents for Amgen’s patient support services, including reimbursement and verification services and the services
provided by field reimbursement professionals in your office, as part of the patient’s treatment with this product and that you have
obtained appropriate patient authorizations as needed.
For any questions, please call (866) AMG-ASST (1-866-264-2778)
Please fax completed forms to Amgen Assist® at 1-888-407-9787
AMGEN ASSIST® is a trademark of Amgen Inc. © 2022 Amgen Inc. All rights reserved.
DIGITAL DOWNLOAD USA-OCF-82046 07/22
MEDICATION AND CODING INFORMATION (Check the medication(s) the patient has been prescribed.)
Product HCPCS Codes ICD/Dx Secondary ICD code Tertiary ICD code
Aranesp® (darbepoetin alfa) injection J0881
BLINCYTO® (blinatumomab) injection J9039
Epogen® (epoetin alfa) injection J0885
IMLYGIC® (talimogene laherparepvec) suspension for injection J9325
KANJINTI® (trastuzumab-anns) for injection
Q5117
Treatment naive? Yes No
KYPROLIS® (carfilzomib) for injection J9047
LUMAKRAS™ (sotorasib) 120 mg tablets N/A
MVASI® (bevacizumab-awwb) for injection
Q5107
Treatment naive? Yes No
Neulasta® (pegfilgrastim) Onpro® injection J2506
Neulasta® (pegfilgrastim) prefilled syringe injection J2506
Parsabiv® (etelcalcetide) injection J0606
NEUPOGEN® (filgrastim) injection J1442
Nplate® (romiplostim) injection J2796
Prolia® (denosumab) injection J0897
RIABNI™ (rituximab-arrx) Q5123
Sensipar™ (cinacalcet) J0604
Vectibix® (panitumumab) injection for IV infusion J9303
XGEVA® (denosumab) injection J0897
Please see Full Prescribing Information, including Boxed WARNINGS and Medication Guide, for Aranesp® at aranesp.com.
Please see Full Prescribing Information, including Boxed WARNINGS and Medication Guide, for BLINCYTO® at blincyto.com.
Please see Full Prescribing Information, including Boxed WARNINGS, for KANJINTI® at kanjinti.com.
Please see Full Prescribing Information, including Boxed WARNINGS and Medication Guide, for RIABNI™ at riabni.com.
Please see Full Prescribing Information, including Boxed WARNINGS, for Vectibix® at vectibix.com.
*For a full list of codes, refer to the Centers for Medicare & Medicaid Services Index 1,2
References: 1. Centers for Medicare & Medicaid Services. July 2022 Alpha-Numeric HCPCS File. Page last modified May 9, 2022. Accessed July 6, 2022.
https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update. 2. Centers for Medicare & Medicaid Services. CMS Manual System.
Transmittal 3685. Accessed July 8, 2022. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3685CP.pdf.
For Neulasta® Onpro® Patients: Send a sharps disposal container? Yes No
Physician Hospital Hospital Home Mail Order Specialty Retail
Site of Care: Office Outpatient Inpatient Health Pharmacy Pharmacy Pharmacy
Other
Optional: Home Health Coverage (If desired, please fill in requested site name for verification.)_____________________________
____________________________________________________________________________________________________________
AFFORDABILITY SCREENING
To see if the patient is eligible for additional affordability options, please complete the questions below
Residency: Patient has lived in the U.S. or its territories (American Samoa, Guam, Puerto Rico, or U.S. Virgin Islands):
Greater than 6 months Less than 6 months
Patient household income: $ ____________________________________________________________ Monthly Annually
(Gross income includes all individuals in the household. This includes wages, Social Security, Social Security disability,
unemployment, pensions, and any other income. They may be asked to provide proof of income.)
How many people live in the patient’s household (including the patient)?: 1 2 3 4 Other ________________
Household size includes all individuals reported on the patient’s U.S. Tax Return. If the patient did not file a tax return please include
all individuals that live with them.
For any questions, please call (866) AMG-ASST (1-866-264-2778)
Please fax completed forms to Amgen Assist® at 1-888-407-9787 2
AMGEN ASSIST® is a trademark of Amgen Inc. © 2022 Amgen Inc. All rights reserved.
DIGITAL DOWNLOAD USA-OCF-82046 07/22
