The product replacement program applies to products that are administered by a provider in an outpatient setting. These include the following products:

About the Enrollment Process

To enroll in these products, the patient’s healthcare provider must first complete a Facility Application Form and be enrolled as a Safety Net Foundation facility. Once enrolled, the provider will then complete and submit the Patient Application Form, along with the patient’s signature and supporting income documentation.

A Patient Application Form needs to be submitted for each patient per enrollment period. The Facility Application Form only needs to be completed once, regardless of the number of patients enrolled or how many products used.

For providers new to The Safety Net Foundation, we recommend calling us to pre-assess patients prior to submitting the Patient Application Form. Foundation staff can also pre-populate many portions of the Patient Application Form and send to the provider or patient for completion and signatures.

Note that the Foundation requires patient consent to release patient-identifiable information to the provider before the patient can be enrolled in the program.

About the Fulfillment Process

The Safety Net Foundation ships all products through a single fulfillment vendor, RxCrossroads®.

RxCrossroads® has both pharmacy and wholesale licenses, allowing two fulfillment delivery models for replacement products offered by the Foundation. The pharmacy model allows the Foundation to ship exact order quantities, while the wholesale model allows the Foundation to ship wholesale volumes to enrolled facilities.

To request replacement product, providers must complete the Product Request Form to document product usage for an enrolled Foundation patient.

The Product Request Form accommodates both fulfillment models. In order to receive exact quantity shipments, a physician must sign the form. If a physician does not sign the form, and only the facility contact signs it, the Foundation will ship the closest wholesale quantity and credit any remaining balance to the facility.

Disclaimer:
The Safety Net Foundation reserves the right to make an independent determination of eligibility in all cases. The Safety Net Foundation also reserves the right to approve or deny any Safety Net Foundation application or to modify or discontinue the program with respect to any patient or provider, or in its entirety, at any time.