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Initiating benefits investigation is easy For your patients/caregivers (Janssen CarePath)

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© Johnson & Johnson Health Care Systems Inc. 2021 5/21 cp-04891v6
Initiating benefits investigation is easy
Here’s what happens next
For prescribers
For prescribers
For your patients/caregivers
For your patients/caregivers
Complete the required Prescriber Information and
Clinical Information sections on pages 1-3
Complete the required Treatment Location Information
section on page 2 (DARZALEX®, DARZALEX FASPRO®,
PROCRIT®, RYBREVANT™, and YONDELIS® only)
Complete the optional Prescription Information and the
Preferred Pharmacy Information sections on page 3
(ERLEADA® and ZYTIGA®
only
)
If prior authorization assistance is NOT needed, check the
appropriate box in the Prior Authorization section on
page 1 to opt out
Janssen CarePath will:
• Medical Benefit: Confirm receipt of requests within
2 hours and verify benefits within 1 to 2 business days
• Pharmacy Benefit: Verify benefits within 4-6 business hours
• Provide you with a verification of benefits and call your
patient to review the benefits
Complete or have your patient complete the Patient
Information and Insurance Information sections on page 4
As requested by your patient, complete or have your patient
complete the Janssen CarePath Savings Program section on
page 5 to determine eligibility
If you do not have a signed Business Associate Agreement
(BAA) on file with Janssen CarePath, have your patient read,
sign, and date the Patient Authorization on pages 6-7
• Give your patient a copy of the signed Patient Authorization
form and keep the original for your records
Janssen CarePath will:
• Call your patient to review the benefits and provide you
with a verification of benefits
• Inform your patient about cost support options and offer
your patient care coordination support services with the
infusion provider or specialty pharmacy
• Enroll your eligible patient with commercial or private health
insurance in the Janssen CarePath Savings Program, if requested
by your patient
YONDELIS® (trabectedin) is under license from Pharma Mar, S.A.
Medical Benefit Pharmacy Benefit
Fax the completed and signed Benefits Investigation Form to Janssen CarePath at 855-998-4422
Need
help?
Call 877-CarePath (877-227-3728)
Monday–Friday, 8:00 am–8:00 pm ET
Multilingual phone support available
Please see full Prescribing Information for DARZALEX®, DARZALEX FASPRO®, RYBREVANT™, YONDELIS®, ERLEADA®, and ZYTIGA®.
Please see full Prescribing Information, including Boxed Warnings and Medication Guide for PROCRIT®. Provide the Medication Guide to your
patients and encourage discussion.
Benefits Investigation Form
© Johnson & Johnson Health Care Systems Inc. 2021 5/21 cp-04891v6
1. Prescriber Information—to be completed by Physician (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 #
2. Prior Authorization—to be completed by Physician (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.
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UPDATE 5.21
By providing your information and information about your patient on the Benefits Investigation Form, you are requesting the services described on this form.
The information you provide will only be used by Johnson & Johnson Health Care Systems Inc., our affiliates, and our service providers involved in delivering these
services. You may withdraw your request for these services by calling 877-CarePath (877-227-3728). Our Privacy Policy governs the use of the information you
provide. By providing the information and submitting this form, you indicate you read, understand, and agree to these terms.
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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Benefits Investigation Form
© Johnson & Johnson Health Care Systems Inc. 2021 5/21 cp-04891v6 2 of 7
DARZALEX® and
DARZALEX FASPRO® only:
Monotherapy
Combination Therapy
If Combination, list medications:
Prior Medications/Treatments:
PROCRIT® only:
Initial HCT %
Initial Hb g/dL
For cancer patients, is the
patient on chemotherapy? Yes No
Is the patient a
nephrology patient? Yes No
If nephrology patient, what is
the patient’s:
Serum creatinine mg/dL
Creatinine clearance mL/min
Is the patient taking
PROCRIT® preoperatively? Yes No
If yes, surgery type
RYBREVANT™ only:
Is the patient
Exon 20 positive? Yes No
Is the patient currently
on or have they previously
taken a platinum-based
chemotherapy? Yes No
If yes, list which platinum-based
chemotherapy:
YONDELIS® only:
Patient Height ft in
Patient BSA
Has the patient taken a
prior chemotherapy? Yes No
If yes, what prior chemotherapy has the
patient taken?
Anthracycline
Ifosfamide
Other
Please investigate benefits for
YONDELIS® infused through an
ambulatory pump through a
central venous catheter
3. Clinical Information for Benefits Investigation: IV/SubQ Only—to be completed by Physician (Required)
Medication
DARZALEX® (daratumumab) DARZALEX FASPRO® (daratumumab and hyaluronidase-fihj) PROCRIT® (epoetin alfa)
RYBREVANT™ (amivantamab-vmjw) YONDELIS® (trabectedin)
Treatment Information
Primary Diagnosis Code Primary Diagnosis Indication
Approximate Date of Patient’s Diagnosis (mm/dd/yyyy)
Secondary Diagnosis (Optional)
Dosage Form and Strength No. of Vials
Administration
Patient Weight lbs kg
Has the patient started therapy with the medication specified above? Yes No
If yes, what date did the patient start therapy? (mm/dd/yyyy)
Additional information regarding treatment (if applicable to benefits verification)
4. Treatment Location Information: IV/SubQ Only—to be completed by Physician (Required)
Treatment Location Type
Prescribing MD’s Office
Non-prescribing MD’s Office Home Infusion/Infusion Provider Company
Hospital Outpatient Hospital Inpatient Other
Provider Information
If prescribing MD’s office, the fields below do not need to be completed if information is the same as the Prescriber Information section.
Provider Name (First, Last) Physician Specialty
Practice Name
Address
City State ZIP
Site Phone Site Fax
Insurance Provider # Tax ID #
Please see full Prescribing Information for DARZALEX®, DARZALEX FASPRO®, RYBREVANT™, and YONDELIS®.
Please see full Prescribing Information, including Boxed Warnings and Medication Guide for PROCRIT®. Provide the Medication Guide to your
patients and encourage discussion.
■
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Benefits Investigation Form
© Johnson & Johnson Health Care Systems Inc. 2021 5/21 cp-04891v6 3 of 7
5. Clinical Information for Benefits Investigation: Orals Only—to be completed by Physician (Required)
Medication
ERLEADA® (apalutamide) 60 mg Tablet Dosing: 240 mg PO once daily with or without food Quantity
ZYTIGA® (abiraterone acetate) 250 mg Tablet 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
Approximate Date of Patient’s Diagnosis (mm/dd/yyyy)
6. Prescription Information: to be completed by Physician (Optional)
If requesting benefits investigation only, do not complete this section. The prescription is only valid if received by fax. If not faxed, prescription must be submitted
on state-specific blank, if applicable for your state.
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 #
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
direct to the patient to be filled at a pharmacy that can fill the script. 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 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: Orals Only—to be completed by Physician (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
Please see full Prescribing Information for ERLEADA® and ZYTIGA®.
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Benefits Investigation Form
© Johnson & Johnson Health Care Systems Inc. 2021 5/21 cp-04891v6
8. Patient Information (Required)
Name (First, MI, Last) Language English Spanish
Male Female Date of Birth (mm/dd/yyyy)
Address
City State ZIP
Primary Email Secondary Email (Optional)
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 Janssen medication indicated on this form, if I am unavailable
when they call.
If I cannot be reached, I authorize Janssen CarePath to contact my caregiver.
I prefer and authorize Janssen CarePath to contact my caregiver in place of me.
9. 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.
Primary Medical Insurance: required for DARZALEX® (daratumumab), DARZALEX FASPRO® (daratumumab and hyaluronidase-fihj),
RYBREVANT™
(amivantamab-vmjw), YONDELIS® (trabectedin), PROCRIT® (epoetin alfa)
Primary Insurance Carrier Phone
Cardholder Name (First, MI, Last) Relationship to Cardholder
Policy # Group #
Secondary Medical Insurance (Optional)
Secondary Insurance Carrier Phone
Cardholder Name (First, MI, Last) Relationship to Cardholder
Policy # Group #
Prescription Drug Insurance: required for ERLEADA® (apalutamide), ZYTIGA® (abiraterone acetate)
Prescription Drug Insurer Card BIN # Phone
Cardholder Name (First, MI, Last) Relationship to Cardholder
Policy # Group #
Please investigate out-of-network benefits.
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Please see full Prescribing Information for DARZALEX®, DARZALEX FASPRO®, RYBREVANT™, YONDELIS®, ERLEADA®, and ZYTIGA®.
Please see full Prescribing Information, including Boxed Warnings and Medication Guide for PROCRIT®. Provide the Medication Guide to your
patients and encourage discussion.
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Benefits Investigation Form
© Johnson & Johnson Health Care Systems Inc. 2021 5/21 cp-04891v6 5 of 7
10. 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 the patient’s eligibility for and enroll the patient into the Janssen CarePath Savings Program if the
results of this benefits investigation determine that the patient has commercial or private health insurance.
Rebate Type for DARZALEX® (daratumumab), DARZALEX FASPRO® (daratumumab and hyaluronidase-fihj),
RYBREVANT™
(amivantamab-vmjw), or YONDELIS® (trabectedin)
Please select how the patient would like to receive their rebate if the consent above is checked and benefits investigation is for DARZALEX®,
DARZALEX FASPRO®, RYBREVANT™, or YONDELIS®
Load Funds onto Card Mail Check to Patient Mail Check to Provider* (please select one option below)
Prescriber Office Treatment Location
Eligibility Questions
1. Will the patient use commercial or private health insurance for their Janssen medication? (Examples are commercial insurance from a
current/former employer, government employee health insurance, or insurance the patient buys privately or through the Health
Insurance Marketplace)
Yes, the patient has commercial or private health insurance that they will use for their Janssen medication
No, the patient does not have commercial or private health insurance that they will use for their Janssen medication
2. Do you confirm the patient will NOT ask any government-funded healthcare program to cover any Janssen medication costs? (Examples are
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 the patient will NOT seek payment from any government-funded healthcare program for their Janssen medication
No, the patient may seek payment from a government-funded healthcare program for their Janssen medication
3. Do you confirm the patient will NOT submit any costs paid by this program as a claim for payment to any health plan, patient assistance
foundation, flexible spending account, or healthcare savings account?
Yes, I confirm that the patient will NOT submit out-of-pocket costs paid by this program as a claim
No, the patient may submit out-of-pocket costs paid by this program as a claim
* By selecting this option, I understand that I am requesting that Janssen CarePath Savings Program rebate check(s) will be sent on behalf of the patient to the designated
provider for payment of the patient’s out-of-pocket Janssen medication costs. I also understand that I may, at any time, call Janssen CarePath and elect for the rebate
check(s) to be sent directly to the patient.
Please see full Prescribing Information for DARZALEX®, DARZALEX FASPRO®, RYBREVANT™, and YONDELIS®.
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Janssen Patient Support Program
Patient Authorization Form
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• Patients should read the Patient Authorization, check the desired permission boxes, and return the form to
Janssen Patient Support Program
• •
Download a copy, print, check the desired boxes, and sign. Your healthcare provider may scan the
completed form and upload on Provider Portal, or completed form may be faxed to 855-998-4422 or mailed
to Janssen CarePath, 2250 Perimeter Park Drive, Suite 300, Morrisville, NC 27560
• •
You may be able to eSign a digital form in your healthcare provider’s office
Patient Name: Email Address:
I give permission for each of my “Healthcare Providers” (eg, my physicians, pharmacists, specialty pharmacies,
other healthcare providers, and their staff) and “Insurers” (eg, my health insurance plans) to share my Protected
Health Information.
My “Protected Health Information” includes but is not limited to the following information related to my medical
condition, treatment, prescriptions, and health insurance coverage.
The following person(s) or class of person(s) are given permission to receive and use my Protected Health
Information (collectively “Janssen”):
• Johnson & Johnson Health Care Systems Inc., its affiliated companies, agents, and representatives
• Providers of other sources of funding include foundations and co-pay assistance providers
• Service providers supporting or analyzing data from Janssen patient support programs
Specifically, I give permission to Janssen to receive, use, and share my Protected Health Information in order to:
• see if I qualify for, sign me up for, and contact me about Janssen patient support programs
• manage the Janssen patient support programs
• give me educational and adherence materials, information, and resources related to my Janssen medication in
connection with Janssen patient support programs
• communicate with my Healthcare Providers regarding access to, reimbursement for, and fulfillment of my
Janssen medication, and to confirm to my Healthcare Provider that support has been provided by the Janssen
patient support programs
• verify, assist with, and coordinate my coverage for my Janssen medication with my Insurers and
Healthcare Providers
•
coordinate prescription or treatment location and associated scheduling
• conduct analysis to help Janssen evaluate, create, and improve its products, services, and customer support
for patients prescribed Janssen medications
• share and give access to information created by the Janssen patient support programs that may be useful
for my care
I understand that my Prote
cted Health Information may be shared by Janssen for the uses written in this Form to:
• My Insurers
• My Healthcare Providers
• Any of the persons given permission to receive and use my Protected Health Information as mentioned above
• Any individual I give permission as an additional contact
I understand that my Protected Health Information will not be used or shared by Janssen for any other use
without my permission. Janssen may share information about me where legally allowed or if any 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 share the information further and that such information provided to a third party
may no longer be protected by federal privacy laws.
© Johnson & Johnson Health Care Systems Inc. 2021 5/21 cp-04891v6
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Janssen Patient Support Program
Patient Authorization Form
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I understand that I am not required to sign this Form. My choice about whether to sign will not change how my
Healthcare Providers or Insurers treat me. If I do not sign this Form, or cancel or remove my permission later, I
understand I will not be able to participate or receive assistance from Janssen’s patient support programs.
This Form will remain in effect 10 years from the date of signature, except where state law requires a shorter time,
or until I am no longer participating in any Janssen patient support programs. Information collected before that
date may continue to be used for the purposes set forth in this Form.
I understand that I may cancel the permissions given by this Form at any time by letting Janssen know in writing at:
Janssen CarePath, 2250 Perimeter Park Drive, Suite 300, Morrisville, NC 27560.
I can also cancel my permission by letting my Healthcare Providers and Insurers know in writing that I do not want
them to share any information with Janssen.
I further understand that if I cancel my permission it will not affect how Janssen uses and shares my Protected
Health Information received by Janssen prior to my cancellation.
I understand I may request a copy of this Form.
Permission for communications outside of Janssen patient support programs:
Yes, I would like to receive communications relating to my Janssen medication.
Yes, I would like to receive communications relating to other Janssen products and services.
For privacy rights and choices specific to California residents, please see Janssen’s California privacy notice
available at https://www.janssen.com/us/privacy-policy#california
Permission for text communications:
Yes, I would like to receive text messages. By selecting this option, I agree to receive text messages as allowed
by this form to the cell phone number provided below. Message and data rates may apply. Message frequency
varies. I understand I am not required to provide my permission to receive text messages to participate in the
Janssen patient support programs or to receive any other communications I have selected.
Cell phone number:
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:
© Johnson & Johnson Health Care Systems Inc. 2021 5/21 cp-04891v6
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Completed 22 July 2021

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