Fill - Free fillable 2020/2021 Patient Enrollment Form Savings Program (Janssen CarePath) PDF form

For assistance or additional information, call 877-CarePath (877-227-3728), Monday–Friday, 8:00 am–8:00 pm ET

PATIENT INFORMATION (*Required)

*Do you have a SIMPONI ARIA

Mastercard

? Yes No If yes, provide 11-digit ID number at bottom of card:

*NAME *GENDER Male Female *DATE OF BIRTH

(MM/DD/YYYY)

*ADDRESS *CITY *STATE *ZIP CODE

*PRIMARY PHONE

(Best number to call 8:00 a m –8:00 pm ET, weekdays) E-MAIL

*If you’re unavailable when we call, is it ok for us to leave a message including the name of your medication? Yes No

Your rebate will be applied to a SIMPONI ARIA

Mastercard to pay for your medication at your treatment provider or pharmacy. This card is not a credit card. There is no charge for this card. If your treatment provider

or pharmacy DOES NOT ACCEPT the SIMPONI ARIA

Mastercard, please call 877-CarePath (877-227-3728), Monday through Friday, 8:00 am –8:00 pm ET, to discuss alternate payment options.

*1. Do you currently have commercial or private health insurance

that you will use for your Janssen medication, including

commercial insurance provided through an employer or former

employer, provided to you as a federal or state employee, and

insurance you pay for yourself, as well as plans available

through state and federal healthcare exchanges?

Yes, I have commercial or private health insurance that I

will use for my Janssen medication

No, I do not have commercial or private health insurance

that I will use for my Janssen medication

*2. Do you confirm that you will NOT seek reimbursement from

any state or federal government-funded healthcare program

to cover a portion of the Janssen medication costs such as

Medicare Parts A, B, C (also known as Medicare Advantage

Plan), D, and Medicare Supplement, Medicaid, TRICARE,

Department of Defense, or Veterans Administration?

Yes, I confirm that I will NOT seek reimbursement from

any state or federal government-funded program for my

Janssen medication

No, I may seek reimbursement from a state or federal

government-funded healthcare program for my

Janssen medication

*3. Do you confirm that you will not submit out-of-pocket costs paid

by this program as a claim for payment to any third-party payer,

pharmaceutical patient assistance foundation, or account such

as a Flexible Spending Account (FSA), a Health Savings Account

(HSA), or a Health Reimbursement Account (HRA)?

Yes, I confirm that I will NOT submit out-of-pocket costs paid

by this program as a claim for payment to any

third-party payer, pharmaceutical patient assistance

foundation, or account

No, I may submit out-of-pocket costs paid by this program

as a claim for payment to a third-party payer, pharmaceutical

patient assistance foundation, or account

Savings Program

2020/2021 Patient Enrollment Form

*Required

*SELECT ONE: Enrollment Update Information Only

Please read the full Prescribing Information, including Boxed Warnings and Medication Guide for SIMPONI ARIA®, and discuss any questions you have with your doctor.

Phone: 877-CarePath (877-227-3728) Fax: 855-820-3224 MyJanssenCarePath.com

Fax or mail completed enrollment form to: Fax: 855-820-3224 Mail: Janssen CarePath Savings Program, 2250 Perimeter Park Drive, Suite 300, Morrisville, NC 27560

My signature below certiﬁes that I have completed all of the above sections completely, accurately, and

to the best of my knowledge, and that I have read, understand, and agree to the Patient Authorization to

release my Protected Health Information as indicated on the next page of this form, including but not

limited to spoken or written facts about my health and payment beneﬁts that I may have. It can include

copies of records from my healthcare providers or health plans about my health or health care. I understand,

accept, and comply with all requirements and restrictions described in the eligibility requirements provided

on the next page and I understand that redeeming this beneﬁt is consistent with the requirements of my

health plan.

PATIENT SIGNATURE

DATE PATIENT NAME

If the patient cannot sign, patient’s personal representative must sign below (Please print)

PATIENT NAME BY

(Signature of person signing for patient)

RELATIONSHIP TO PATIENT AND AUTHORITY TO MAKE MEDICAL DECISIONS FOR PATIENT

YOUR PRESCRIBER (*Required)

*PRESCRIBER NAME *PRACTICE NAME

*ADDRESS *CITY *STATE *ZIP CODE

*PHONE # *OFFICE–MAIN FAX #

TREATMENT PROVIDER INFORMATION (This section does not need to be completed if information is the same as “YOUR PRESCRIBER”)

NAME OF PHYSICIAN OFFICE/HOSPITAL/OTHER NAME

ADDRESS CITY STATE ZIP CODE

PHONE # OFFICE–MAIN FAX #

Non-prescribing MD’s Ofﬁce Hospital Outpatient Home Treatment/Treatment Provider Company Other

NOTE: PLEASE READ THE PATIENT ELIGIBILITY REQUIREMENTS ON THE NEXT PAGE PRIOR TO COMPLETING THIS FORM.

By submitting this form, I am requesting to be enrolled in Janssen CarePath Savings Program for SIMPONI ARIA

(the

“Program”). I understand that my personal information will be used by Janssen Biotech, Inc., the maker of SIMPONI ARIA

including our affiliates and our service providers that work on their behalf (the “Companies”), in connection with the

Program, to help me get assistance with the costs of SIMPONI ARIA

, or as otherwise required or allowed under the law.

I also understand that the Companies may use my name and contact information for market and outcomes research and

to improve the information that the Companies provide to patients who are being treated with SIMPONI ARIA

I understand that the Companies may de-identify my information and use or disclose the de-identified information for any

purpose permitted by law. I understand that they will take commercially reasonable efforts to keep my information private.

I understand that the Companies may contact me by telephone, postal mail, or e-mail (if I provide an e-mail), in connection

with my enrollment in the Program. I understand and agree that by enrolling in the Program I may also enroll to receive

the information and resources provided by Janssen CarePath, a support program for SIMPONI ARIA

and other Janssen

Biotech, Inc., products. If I choose to participate, the information and resources may include providing educational materials

related to my treatment. Janssen CarePath will also contact my provider as necessary to administer support that I request.

I understand that if I am using medical/primary insurance to pay for my Janssen medication, I am responsible for submitting

a rebate request including an Explanation of Benefits (EOB) to receive payment following each treatment. At my direction,

my provider may submit the rebate request on my behalf. I will coordinate with my provider who will submit the rebate

request. The Program will use the information my provider or I submit to determine the amount of costs for SIMPONI ARIA

that Janssen Biotech, Inc., will reimburse. That amount will be credited to my SIMPONI ARIA

Mastercard. I further

understand that if my provider or I do not submit an EOB or pharmacy receipt, the Program cannot process my rebate

request. I understand that I can use my Savings Program card for instant savings if SIMPONI ARIA

is obtained from a

pharmacy and that if the pharmacy is unable to process my Savings Program card, I will receive a rebate by submitting

my pharmacy receipt. I understand that if a pharmacy provides SIMPONI ARIA

to my treatment provider, and can accept

SIMPONI ARIA

Mastercard, the rebate for SIMPONI ARIA

will be credited to my SIMPONI ARIA

Mastercard to pay for

SIMPONI ARIA

at the pharmacy. By participating in the Savings Program, I am giving permission for information related

to my Savings Program transactions, including rebates and any funds placed on or balance remaining on the Savings

Program card, to be shared with my healthcare provider(s).

I understand that I can cancel participation in the Program at any time by notifying Janssen CarePath at

877-CarePath (877-227-3728). Our Privacy Policy governs the use of the information you provide. I understand

that, if I am enrolled in the Program, Janssen Biotech, Inc., will not be responsible for lost or stolen cards or for

any misuse of these cards.

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Patient Authorization

Patients must read this and sign the acknowledgment on the previous page before they can participate in the Program.

My signature on the previous page of this form confirms that I authorize each of my physicians, pharmacists, including any specialty pharmacy that receives my prescription for a Janssen

medication and other healthcare providers (together, “Healthcare Providers”) and each of my health insurers (together, “Insurers”) to disclose my protected health information, including

but not limited to information related to my medical condition and treatment, my health insurance coverage, my name, address, telephone number, insurance plan and/or group numbers

(together, “Protected Health Information”) to Johnson & Johnson Health Care Systems Inc., its affiliated companies, agents, and representatives (together, “Janssen”), including providers

of alternate sources of funding for prescription drug costs, and other approved service providers authorized to manage, administer, and/or support Janssen CarePath programs, Janssen

CarePath Account for Patients, and Provider Portal for their Healthcare Providers for the purposes described below.

Specifically, I authorize Janssen to receive, use, and disclose my Protected Health Information in order to (i) enroll me in, determine my eligibility for, and contact me about Janssen

medication support programs; (ii) provide me with educational materials, information, and services related to my Janssen medication; (iii) verify, investigate, assist with, and coordinate

my coverage for my Janssen medication with my Insurers; (iv) coordinate prescription fulfillment; (v) assist with analyses related to the quality, efficacy, and safety of my Janssen medication,

and patient access to and adherence to my Janssen medication; (vi) share and provide access to information generated by Janssen CarePath that may be useful for my care, and;

(vii) improve, develop, and evaluate Janssen CarePath, its offerings, and materials. I also understand that pharmacies that ship my medication may be paid to share this information with

Janssen CarePath to help provide the offerings requested for me. Furthermore, I understand that my Protected Health Information will not be used or disclosed by Janssen for any other

purpose without my prior authorization unless permitted by law or unless information that specifically identifies me is removed. I understand that Janssen will make every effort to keep

my information private. Further, I understand that if my information is accidentally shared, federal privacy laws do not require that the person/party receiving it not disclose the information

further and that such information provided to a third party may no longer be protected by federal privacy laws.

I understand that I am not required to sign this form on the previous page. My choice about whether to sign will not change the way my Healthcare Providers or Insurers treat me. If I refuse

to sign on the previous page of this form, or revoke my authorization later, I understand that this means I will not be able to participate or receive assistance from Janssen CarePath.

This authorization will last until I am no longer participating in Janssen CarePath or accessing my Janssen CarePath Account. I understand that I may cancel or revoke this Authorization

at any time by mailing a letter requesting such cancellation to Janssen CarePath, 2250 Perimeter Park Drive, Suite 300, Morrisville, NC 27560 or by informing my Healthcare Providers and

surers in writing that I do not want them to share any information with Janssen. I further understand that cancellation or revocation will not affect Janssen’s ability to use and disclose

Protected Health Information that it has received prior to its receipt of my cancellation and revocation of participation in the program. My authorization will also end if Janssen CarePath

support programs or the Janssen CarePath Account is discontinued. Furthermore, I understand that I have the right to see or copy the Protected Health Information my Healthcare

Providers or Insurers have given to Janssen.

Patient Eligibility Requirements for Janssen CarePath Savings Program

Benefits are available to individuals who currently use commercial or private health insurance to cover a portion of the medication costs

for SIMPONI ARIA® (golimumab). There is no income requirement. Janssen CarePath Savings Program for SIMPONI ARIA® is based on

medication costs only and does not include costs to give you your infusions.

Other Requirements:

• This program is only available to individuals age 2 or older using commercial or private health insurance for their Janssen medication, including plans available through state and

federal healthcare exchanges. This program is not available to individuals who use any state or federal government-funded healthcare program to cover a portion of medication costs,

such as Medicare, Medicaid, TRICARE, Department of Defense, or Veterans Administration.

• Out-of-pocket costs paid by this program may not be submitted as a claim for payment to any third-party payer, pharmaceutical patient assistance foundation, or account such as a

Flexible Spending Account (FSA), a Health Savings Account (HSA), or a Health Reimbursement Account (HRA).

• Your eligibility to receive a Savings Program benefit is subject to meeting the program requirements at the time of each Savings Program request.

• Program terms will expire at the end of each calendar year. Program subject to change or discontinuation without notice, including in specific states.

• As a condition of participating in this program, you must ensure that you comply with any co-payment disclosure requirements of your insurance carrier or third-party payer, including

disclosing to your insurer the amount of co-payment support you receive from this program. By receiving a Savings Program benefit, you confirm that you have read, understood, and

agree to the program requirements shown on this page, and you are giving permission for information related to your Savings Program transactions, including rebates and any funds

placed on or balance remaining on the Savings Program card, to be shared with your healthcare provider(s).

• Before you activate your card, it is important that you understand that you will be asked to provide personal information that may include your name, address, phone number, email

address, and information related to your prescription medication insurance and treatment. This information is necessary to permit Janssen Biotech, Inc., the maker of SIMPONI ARIA

and companies that work with Janssen Biotech, Inc., including our affiliates and our service providers, to fulfill your request to enroll in the Janssen CarePath Savings Program. We may

also use the information you give us to learn more about the people who use SIMPONI ARIA

, and to improve the information we provide to people who are being treated with

SIMPONIARIA

. Janssen Biotech, Inc., will not share your information with anyone else except as required by law.

• If you use medical/primary insurance to pay for your medication, you are responsible for submitting a rebate request including an Explanation of Benefits (EOB) to receive payment

under the Savings Program. At your direction, your provider may submit the rebate request and EOB on your behalf. Please ensure you and your provider coordinate who will submit

the rebate request.

• This program offer may not be combined with any other coupon, discount, prescription savings card, free trial, or other offer for reduced medication cost. The selling, purchasing,

trading, or counterfeiting of this card is prohibited. Offer good only in the United States and its territories. Void where prohibited, taxed, or otherwise restricted by law.

Janssen CarePath is in no way an extension of medical treatment provided by healthcare professionals to individual patients. You may discontinue your participation at any time by calling

877-CarePath (877-227-3728).

3 ways to enroll: Review the program requirements above, then choose the enrollment option you prefer:

NOTE: Your signature on the previous page of this form certifies:

• That you understand, accept, and comply with all requirements described above, and that your participation in the Program is consistent with the requirements of your health plan.

• That you have read, understand, and agree to the Patient Authorization to release your Protected Health Information as indicated above, including but not limited to spoken or written

facts about your health and payment benefits you may have. It can include copies of records from your healthcare providers or health plans about your health or health care.

Form:

Complete and sign the previous page of this form, and fax or mail to:

Fax: 855-820-3224 OR Mail: Janssen CarePath Savings Program

2250 Perimeter Park Drive, Suite 300

Morrisville, NC 27560

Online:

MyJanssenCarePath.com

Phone:

877-CarePath (877-227-3728)

Janssen Biotech, Inc., is not liable for unintended or unauthorized use of the SIMPONI ARIA

Mastercard, if it is lost or stolen. The Janssen CarePath Savings Program for SIMPONI ARIA

Prepaid Mastercard is issued by MetaBank

, N.A., Member FDIC, pursuant to license by Mastercard International Incorporated. Mastercard is a registered trademark, and the circles design

is a trademark of Mastercard International Incorporated. Janssen CarePath Savings Program is not a MetaBank or Mastercard product or service, nor is the optional offer endorsed by them.

Please read the full Prescribing Information, including Boxed Warnings and Medication Guide for

SIMPONI ARIA®, and discuss any questions you have with your doctor.

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