Enrollment Is Simple:
1. Read and understand the Nplate™ package insert and the requirements of the Nplate™
    NEXUS Program.

2. Review, complete, and submit the Nplate™ NEXUS Program Healthcare Provider Enrollment
    Form. Provider enrollment is completed only once.

3. Identify an appropriate patient for Nplate™, educate the patient on the risks and benefits of
    treatment with Nplate™, make sure that the patient receives the Medication Guide, instruct
    the patient to read it, and encourage the patient to ask questions when considering
    Nplate™.

4. Review, complete, and submit the Nplate™ NEXUS Program Patient Enrollment Form,
    answer all questions, and obtain the patient’s signature on the Nplate™ NEXUS Program
    Patient Enrollment Form. Keep the original, send a copy according to Nplate™ NEXUS
    Program instructions, and give a copy to the patient.

5. Complete and submit the Nplate™ NEXUS Program Patient Baseline Data Form. Fax
    completed forms to 1-877-NPLATE0 (1-877-675-2830) using the forms provided in your
    Nplate™ NEXUS Program Training Kit, or click here to download the forms.


Hospital and Institutional Enrollment (not for individual practices)

The Nplate™ NEXUS Program offers the flexibility of institutional enrollment.
Hospitals and other healthcare institutions may enroll by submitting an Nplate™ NEXUS Program Institution Enrollment Form. Upon enrollment, an institution may designate an Nplate™ NEXUS Program point of contact for the institution. The designated person may
be a hospital administrator, pharmacy director, clinical pharmacist, or any staff member the institution deems appropriate to internally coordinate Nplate™ NEXUS Program activities.

During enrollment, the designated person will complete an Nplate™ NEXUS Program Institution Enrollment Form agreeing to the following:

• Develop a system, order sets, protocols, or other measures to ensure that Nplate™ is only dispensed to inpatients and outpatients (eg, in a clinic) after verifying that the prescribing healthcare provider and patient are enrolled in the Nplate™ NEXUS Program;
• Train and provide educational materials to appropriate staff responsible for prescribing, dispensing and adminstering Nplate™ regarding the safe and appropriate use of Nplate™, program monitoring requirements (including dispensing the medication guide with each dose), program adverse event reporting requirements, and institution documentation requirements;
• Develop a system to ensure patients started on Nplate™ as inpatients are transitioned to an outpatient healthcare provider that is enrolled (or will be enrolled) in the Nplate™ NEXUS Program; and
• Develop a process and system to track Nplate™ NEXUS Program compliance and cooperate with periodic audits to assure that Nplate™ is used in accordance with the program requirements. Product tracking includes the following information:

The designated contact will receive the Nplate™ NEXUS Program Training Kits for in-house training along with copies of the Nplate™ Medication Guide. NEXUS Specialists and Amgen representatives will be available as resources to institutions and assist healthcare providers in enrollment and training.

Please Note: In addition, to institutional enrollment, all individual healthcare providers must be enrolled in the Nplate™ NEXUS Program in order to prescribe Nplate™.

Amgen will be regularly evaluating program compliance to ensure that program objectives are met. Amgen reserves the right to terminate an institutional enrollment at any time based upon the institution's non-compliance with program requirements, or take other appropriate measures to assure that program objectives are met.

Connecting With Nplate™ (romiplostim) Therapy:
The 5 Steps of the Nplate™ NEXUS Program