Fillable Benefits Investigation Form (Janssen CarePath)

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Benefits Investigation Form (Janssen CarePath)

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© Janssen Biotech, Inc. 2020 9/20 cp-89790v2
Benefits Investigation Form
Fax the completed and signed Benefits Investigation Form to Janssen CarePath at 855-998-4422.
For assistance, call 877-CarePath (877-227-3728), Monday–Friday, 8:00
am–8:00 pm ET
Janssen CarePath cannot accept any information without an executed Business Associate Agreement or Patient Authorization Form, which can be found at JanssenCarePath.com or as the last page of this document.
The information you provide will be used by Janssen Biotech, Inc., our affiliates, and our service providers for your enrollment and participation in Janssen CarePath. You may withdraw by calling 877-CarePath (877-227-3728).
Our Privacy Policy further governs the use of the information you provide. By providing the information and submitting this form, you indicate that you read, understand, and agree to these terms.
UPDATE 9.20
Please see full Prescribing Information for ERLEADA® and ZYTIGA®.
1. PATIENT INFORMATION (Required)
NAME (First, MI, Last) LANGUAGE English Spanish
Male Female DATE OF BIRTH MMDDYYYY EMAIL
ADDRESS CITY STATE ZIP
PRIMARY PHONE SECONDARY PHONE (Optional) BEST TIME TO CONTACT
CAREGIVERCONTACT
(A caregiver/contact is someone who can be contacted in place of the patient)
HOMECELL PHONE WORK PHONE BEST TIME TO CONTACT
I authorize Janssen CarePath to leave a message, including the name of the If I cannot be reached, I authorize Janssen CarePath to contact my caregiver.
Janssen medication indicated on this form, if I am unavailable when they call.
I prefer and authorize Janssen CarePath to contact my caregiver in place of me.
Please sign patient authorization section on page 4.
2. INSURANCE INFORMATION (Required) Please provide insurance information for all health insurance coverage you may have.
Please see attached front and back copy of insurance card. Please investigate out-of-network benefits.
PRESCRIPTION DRUG INSURANCE
CARD BIN # PHONE
CARDHOLDER NAME (First, MI, Last)
RELATIONSHIP TO CARDHOLDER
POLICY # GROUP #
PRIMARY MEDICAL INSURANCE
PHONE
CARDHOLDER NAME (First, MI, Last)
RELATIONSHIP TO CARDHOLDER
POLICY # GROUP #
3. PRESCRIBER INFORMATION (Required)
PRESCRIBER NAME FIRST, LAST SPECIALTY
PRACTICE NAME OFFICE CONTACT
ADDRESS CITY STATE ZIP
EMAIL PHONE FAX
MEDICAIDMEDICARE PROVIDER # TAX ID #
STATE LICENSE # UPINNPI #
4. PRIOR AUTHORIZATION (Optional) Automatically provided with benefits investigation. You may opt out by checking the box below.
PRIOR AUTHORIZATION FORM ASSISTANCE AND STATUS MONITORING: Janssen CarePath assists your office in providing the requirements of the patient’s health plan related to prior
authorization for treatment with the medication specified on this form. Assistance includes obtaining the health-plan-specific prior authorization form and providing it based upon the
patient-specific information provided on this form. The partially completed prior authorization form, if received from the health plan, will be provided to your office for possible completion
and submission in the office’s sole discretion. Janssen CarePath also actively monitors the status of prior authorization submission to the patient’s plan and provides status updates to your
office with respect to this patient’s prior authorization for treatment with the medication specified on this form.
I do NOT wish to receive Prior Authorization Form Assistance or Status Monitoring.
5. CLINICAL INFORMATION FOR BENEFITS INVESTIGATION (Required)
Medication
ERLEADA® (apalutamide) 60 mg Tablet DOSING: 240 mg PO once daily with or without food QUANTITY:
OR
ZYTIGA® (abiraterone acetate) 250 mg Tablet, OR DOSING: mg PO daily on an empty stomach QUANTITY:
500 mg Film-Coated Tablet DOSING: mg PO daily on an empty stomach QUANTITY:
Treatment Information
PRIMARY DIAGNOSIS CODE: C61* PRIMARY DIAGNOSIS INDICATION: Malignant neoplasm of prostate
*2019 ICD-10-CM Diagnosis Code
APPROXIMATE DATE OF PATIENT’S DIAGNOSIS (mm/dd/yyyy)
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© Janssen Biotech, Inc. 2020 9/20 cp-89790v2
Patient insurance benefits investigation and other Janssen CarePath program offerings are provided by third-party service providers
for Janssen CarePath, under contract with Johnson & Johnson Health Care Systems Inc. on behalf of Janssen Pharmaceuticals, Inc.,
Janssen Biotech, Inc., and Janssen Products, LP (Janssen). Janssen CarePath is not available to patients participating in the Patient
Assistance Program offered by Johnson & Johnson Patient Assistance Foundation. The availability of information and assistance may
vary based on the Janssen medication, geography and other program differences. Janssen CarePath assists healthcare providers
(HCPs) in the determination of whether treatment could be covered by the applicable third-party payer based on coverage guidelines
provided by the payer, and patient information provided by the HCP under appropriate authorization following the provider’s exclusive
determination of medical necessity. This information and assistance are made available as a convenience to patients, and there is
no requirement that patients or HCPs use any Janssen product in exchange for this information or assistance. Janssen assumes no
responsibility for and does not guarantee the quality, scope, or availability of the information and assistance provided. The third-party
service providers, not Janssen, are responsible for the information and assistance provided under this program. Each HCP and patient
is responsible for verifying or confirming any information provided. All claims and other submissions to payers should be in compliance
with all applicable requirements.
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© Janssen Biotech, Inc. 2020 9/20 cp-89790v2
Benefits Investigation Form
Please see full Prescribing Information for ERLEADA® and ZYTIGA®.
6. PRESCRIPTION INFORMATION: TO BE COMPLETED BY PHYSICIAN (Optional) If requesting benefits investigation only, do not complete this section.
PATIENT NAME (First, MI, Last) DATE OF BIRTH
Rx ERLEADA® 60 mg Tablet
DIRECTIONS: Take 240 mg PO once daily with or without food. QUANTITY REFILLS #
OR
Rx ZYTIGA® 250 mg Tablet 500 mg Film-Coated Tablet
DIRECTIONS: Take mg PO daily on an empty stomach. QUANTITY REFILLS #
INITIAL DOSING: For patients with baseline moderate hepatic impairment (Child-Pugh Class B), reduce the ZYTIGA® starting dose to 250 mg once daily (see Dose Medication Guidelines
for more information). Do not use ZYTIGA® in women who are or may become pregnant and patients with baseline severe hepatic impairment (Child-Pugh Class C). Refer to the ZYTIGA®
full PRESCRIBING INFORMATION, including the following sections: INDICATIONS AND USAGE, CONTRAINDICATIONS, DOSAGE AND ADMINISTRATION, WARNINGS AND PRECAUTIONS,
ADVERSE REACTIONS, DRUG INTERACTIONS, and USE IN SPECIFIC POPULATIONS prior to initiating treatment.
Rx Prednisone 5 mg tablet
DIRECTIONS: Take QUANTITY REFILLS #
Prednisone is required to be taken with ZYTIGA®; however, it is optional to include on this Benefits Investigation Form. You may provide a prescription directly to the patient to
be filled at a pharmacy of his choice. NOTE: Janssen CarePath will not investigate benefits for prednisone. Please refer to full Prescribing Information for complete information
prior to initiating treatment.
PRESCRIBER NAME (if different from page 1)
ADDRESS
CITY STATE ZIP
PHONE FAX
PRESCRIBER SIGNATURE (NO STAMPS) REQUIRED. I certify that therapy with the Janssen medication indicated above is medically necessary for this patient. I will be supervising the
patient’s treatment accordingly, and I have reviewed the current full Prescribing Information for the Janssen medication indicated above. I authorize Janssen CarePath to act on my
behalf for the limited purposes of transmitting this prescription to the appropriate pharmacy designated by me, the patient, or the patient’s plan.
PRESCRIBER SIGNATURE >> (Dispense as written) DATE
PRESCRIBER SIGNATURE >> (Substitutions allowed) DATE
SUPERVISING PHYSICIAN SIGNATURE >> (If applicable) DATE
SUPERVISING PHYSICIAN NAME
7. PREFERRED PHARMACY (Optional)
As the treating physician, I have discussed preference for a Specialty Pharmacy (SP) with this patient. This patient prefers use of the SP indicated below. I authorize Janssen Biotech, Inc.,
and its representatives to fax this prescription to: 1. The SP designated below, provided it is approved by this patient’s plan. 2. If the SP designated is not a plan-approved SP, then to an SP
approved by this patient’s plan. 3. If there is no preferred SP indicated, then to any SP approved by this patient’s plan.
PREFERRED SPECIALTY PHARMACY Self-Dispensing Pharmacy
8. ZYTIGA AFTER ERLEADA™ VOUCHER PROGRAM (Optional)
The ZYTIGA AFTER ERLEADA™ Voucher Program from Janssen CarePath helps support continuity of care and gives providers and eligible patients the chance to assess the
efficacy, safety, and tolerability of ZYTIGA® for up to 4 months at no cost to the patient. At the conclusion of the program, you and your patient decide if it is appropriate to
continue treatment. For a digital version of the Voucher Program Enrollment Form, click here or call 877-CarePath (877-227-3728), Monday through Friday, 8:00
am
to 8:00
pm
ET.
I would like to receive information about the ZYTIGA AFTER ERLEADA™ Voucher Program from Janssen CarePath.
9. JANSSEN CAREPATH SAVINGS PROGRAM (Optional)
Eligible patients using commercial insurance can save on out-of-pocket Janssen medication costs. See program requirements at JanssenCarePath.com.
I would like Janssen CarePath to check my eligibility for and enroll me into the Janssen CarePath Savings Program if the results of this benefits investigation determine I have commercial
or private health insurance.
ELIGIBILITY QUESTIONS
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.
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© Janssen Biotech, Inc. 2020 9/20 cp-89790v2
Janssen CarePath
2250 Perimeter Park Drive, Suite 300
Morrisville, NC 27560
Fax 855-998-4422
• Patients should read the Patient Authorization and sign electronically or download, print, and sign.
- Completed form may be uploaded to Patient Account or Provider Portal, faxed to Janssen CarePath at 855-998-4422,
or mailed to address below.
• Patients can access a copy of completed form in their Janssen CarePath Account – My Profile.
My signature on this Patient Authorization 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) to share and provide access to, information generated by Janssen CarePath that may be
useful for my care, and; (vii) to 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 Patient Authorization Form. My choice about whether to sign will not change the way my Healthcare
Providers or Insurers treat me. If I refuse to sign the Patient Authorization 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 Insurers 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 name: Date of birth (mm/dd/yyyy):
Patient address:
City: State: ZIP Code:
Patient sign here: Date:
If the patient cannot sign, patient’s legally authorized representative must sign below:
By: Date:
(Signature of person legally authorized to sign for patient)
Describe relationship to patient and authority to make medical decisions for patient:
Janssen CarePath Patient Authorization
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Benefits Investigation Form (Janssen CarePath)

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Completed 22 July 2021

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