Fillable Patient Assistance Program Application

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Patient Assistance Program Application

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© Johnson & Johnson Patient Assistance Foundation, Inc. page 1 of 5Revised: August 2020
The Johnson & Johnson Patient Assistance Foundation, Inc. (JJPAF) is an independent, non-profit organization that is committed to
helping eligible patients without insurance coverage receive prescription products donated by Johnson & Johnson operating companies.
You may be eligible for our free prescription program for up to one year if you meet the requirements below:
• You have been prescribed a Johnson & Johnson operating company donated medication
• You meet the eligibility income requirements for the medication(s)
• You don’t have insurance or medicine is not covered
— Some p
atients with Medicare Prescription Drug Coverage (Part D) who cannot aord their medicines and who meet certain
financial criteria may also be eligible for assistance. A report from your pharmacy or an Explanation of Benefits (EOB) statement
from your insurer that shows your out-of-pocket costs for the current year can be requested and may be submitted with your
application. In order to qualify for the program, you must spend 4% or more of your gross annual income on prescription drugs.
• You live in the United States or a U.S. territory
• You are being treated by a U.S. licensed doctor as an outpatient
PATIENT CHECKLIST FOR SUBMITTING AN APPLICATION
Read the Patient Declaration and Patient Authorization to Share
Health Information on page 4, then complete all relevant patient
information on page 2, and sign and date as required
Include a copy of the front and back of your insurance card
Include a copy of your most recent 1040 or 1040EZ Federal
tax return
Ask your Healthcare Professional (HCP) to complete, and
sign and date page 3
Submit completed pages 2 and 3 only with documentation to:
Mail: Johnson & Johnson Patient Assistance Foundation, Inc.
Patient Assistance Program
PO Box 0367, Chesterfield, MO 63006
Fax: 1-888-526-5168
If you have questions about Johnson & Johnson Patient Assistance Foundation, Inc. (JJPAF) or how to complete this form, please contact us at
1-800-652-6227, 9am – 6pm EST, Monday through Friday.
Missing information and/or required documents may delay processing of application.
MEDICATIONS AVAILABLE THROUGH THE PATIENT ASSISTANCE PROGRAM
Medications shipped to the patient's residence
BALVERSA®
(erdafitinib) Tablets
ERLEADA® (apalutamide) Tablets
IMBRUVICA® (ibrutinib) Capsules or Tablets
ZYTIGA® (abiraterone acetate) Tablets
Medications shipped to the HCP's oce
DARZALEX®
(daratumumab) Injection for intravenous infusion
DARZALEX FASPRO™ (daratumumab and hyaluronidase-fihj), Injection for
subcutaneous use
HALDOL® Decanoate* (haloperidol decanoate) Injection for
extended-duration for eect
INVEGA SUSTENNA®* (paliperidone palmitate) Extended-release
Injectable Suspension
INVEGA TRINZA®* (paliperidone palmitate) Extended-release
Injectable Suspension
MONOVISC® (high molecular weight hyaluronan) Injection
ORTHOVISC® (high molecular weight hyaluronan) Injection
REMICADE®* (infliximab) Intravenous Infusion
RISPERDAL CONSTA®* (risperidone) Long-acting Injection
SIMPONI ARIA®* (golimumab) Intravenous Infusion
STELARA®
†
(ustekinumab) Injection, for subcutaneous or intravenous use
TREMFYA® (guselkumab) Prefilled syringe or One-Press
patient-controlled injector
YONDELIS® (trabectedin) Injection for intravenous infusion
Medications available through retail or specialty pharmacy.
HCP must provide a prescription.
CONCER
TA®*
(methylphenidate HCI) Extended-release Tablets CII
EDURANT® (rilpivirine) Tablets
ELMIRON® (pentosan polysulfate sodium) Capsules
INTELENCE® (etravirine) Tablets
INVOKAMET®* (canagliflozin/metformin HCI) Tablets
INVOKAMET® XR* (canagliflozin/metformin HCI) Extended-release Tablets
INVOKANA®* (canagliflozin) Tablets
PREZCOBIX® (darunavir 800mg/cobicistat 150mg) Tablets
PREZISTA® (darunavir) Tablets or Oral Suspension
PROCRIT®* (epoetin alfa) Injection, for subcutaneous or intravenous use
SIMPONI®* (golimumab) SmartJect® or Prefilled syringe
SIRTURO® (bedaquiline) Tablets
SPORANOX®* (itraconazole) Capsules or Oral Solution
SPRAVATO®* (esketamine) Nasal Spray CIII, for intranasal use
STELARA®
†
(ustekinumab) Injection, for subcutaneous or intravenous use
SYMTUZA® (darunavir, cobicistat, emtricitabine, and
tenofovir alafenamide) Tablets
TREMFYA® (guselkumab) Prefilled syringe or One-Press
patient-controlled injector
XARELTO®* (rivaroxaban) Tablets
*
See full U.S. Prescribing Information, including Black Box warning.
†
May be distributed via pharmacy or shipped to HCP.
Patient Assistance Program Application
INSTRUCTIONS FOR ENROLLMENT
© Johnson & Johnson Patient Assistance Foundation, Inc. page 2 of 5Revised: August 2020
Patient Assistance Program Application
TO BE COMPLETED BY THE PATIENT See checklist on page 1—all information is required.
Signature and date required before submission.
My signature below indicates that I have read, understand, and agree to the Patient Declaration and Patient Authorization to Share Health
Information on page 4. If I have listed an authorized representative below, I permit the Johnson & Johnson Patient Assistance Foundation, Inc.
(JJPAF) to discuss my application with this person. This includes the status of my application, insurance and financial questions, any missing
documentation, and other issues related to my application and participation, throughout my enrollment period in the program. By signing below,
this representative is allowed to speak on my behalf regarding my application with JJPAF.
Patient Name (print): Date:
Authorized Representative Name (print if applicable):
Relationship to Patient (print if applicable): Phone:
Please Sign:
Date:
Patient Signature/Authorized Representative
4 Patient Declaration/Authorization to Assign Representative for Program Enrollment
Name: Phone: Email:
Social Security #: Date of Birth: Gender: Male Female
Address (Street, City, State, ZIP):
1 Patient Information
Total Gross Yearly Income
Entire household: $
Household Size
Including yourself, the number of people who live in your home and are
dependent on your household income:
Federal Taxes (Select one of the options below.)
A copy of my most recent 1040 or 1040EZ Federal tax
return is attached. Not required for SIRTURO® applications.
I do not file Federal taxes.
(Tax returns may be reviewed and additional documentation requested.)
2 Financial Information
3 Healthcare Insurance Information (Select all that apply.) Please attach a copy of your insurance card.
Check if no insurance
ID/Policy # Group # Phone
Prescription Insurance/Medicare Part D Plan
Plan Name: Fax:
Rx BIN #: Rx PCN:
Private/Commercial Insurance
Medicaid
Medicare Part B
Medicare Advantage
Veterans Administration
ADAP AIDS
SPAP State Patient Assistance Program
Other:
Subscriber Name: Date of Birth: Relationship to Patient:
Primary Plan Name: Secondary Plan Name:
SUBMIT THIS PAGE
© Johnson & Johnson Patient Assistance Foundation, Inc. page 3 of 5Revised: August 2020
TO BE COMPLETED BY THE HEALTHCARE PROFESSIONAL (HCP)—all information is required.
Name: Site Name:
Site Contact: Business Hours:
Address (City, State, ZIP):
Phone: Fax: Email:
Tax ID #: NPI # (required):
State License # (required): Expiration (mm/yyyy): DEA # (required):
Collaborating MD (for mid-level providers): Collaborating MD NPI # (required):
Provider Transaction Access Number (PTAN) (required if the patient has Medicare):
HCP Distribution Shipping Address or SPRAVATO® REMS-Certified Treatment Center Address (if dierent from above):
Site Name: Contact Name for Shipment:
Business Hours: Phone: Fax:
Address (City, State, ZIP):
Please note, Florida HCPs may be required to provide Florida Pedigree information at time of first shipment.
2 HCP Information
1 Prescription (If requesting more than 1 product, attach additional prescription information.)
Patient Name:
Date of Birth:
ICD Code (HCP-administered products only):
Name of Product:
Strength:
Sig:
Quantity:
Days’ Supply:
Number of Refills (maximum 11):
BALVERSA®, ERLEADA®, IMBRUVICA®, or ZYTIGA®:
• If you are a prescriber in New York, South Carolina, or Washington and
are requesting BALVERSA®, ERLEADA®, IMBRUVICA®, or ZYTIGA®,
you must attach prescription on your state ocial prescription form
with this application.
BALVERSA®, ERLEADA®, IMBRUVICA®, or ZYTIGA®:
• List any patient allergies:
or NKDA
BALVERSA®, ERLEADA®, IMBRUVICA®, or ZYTIGA®:
• List patient’s current medications:
or none
BALVERSA®:
• Has the patient tested positive for FGFR? Yes No
HIV Medication:
• Check if patient is currently taking: PREZISTA® PREZCOBIX®
INTELENCE® EDURANT® SYMTUZA®
PROCRIT®*:
• Hemoglobin level based on most recent lab results:
• Required: Is the patient being treated on renal dialysis? Yes
†
No
Select STELARA® Distribution Option (must select one):
Ship to HCP’s oce
Retail or specialty pharmacy. HCP must provide a prescription.
Select TREMFYA® Distribution Option (must select one):
Ship to HCP’s oce
Retail or specialty pharmacy. HCP must provide a prescription.
*See full U.S. prescribing information, including Black Box warning.
†
Contact Amgen Inc. 1-800-772-6436.
3 HCP Authorization
My signature below indicates that I have read, understand, and agree to the Johnson & Johnson Patient Assistance Foundation, Inc. policy
and the terms of Program participation on page 5.
Healthcare Professional Signature:
Date:
Patient Assistance Program Application
SUBMIT THIS PAGE
Print Form
© Johnson & Johnson Patient Assistance Foundation, Inc. page 4 of 5
PATIENT DECLARATION AND PATIENT AUTHORIZATION TO SHARE HEALTH INFORMATION
Please read, sign and date on page 2, Patient Section 4.
I promise:
•
The information on this form is correct and complete including all copies of documents proving my income.
•
The product(s) provided under this patient assistance program will not be sold or traded.
•
I will notify the Johnson & Johnson Patient Assistance Foundation, Inc. (JJPAF) Patient Assistance Program ("Program") within
thirty (30) days if there is any change in the status of my eligibility (related to changes in income or health coverage) to receive
products through this program. This includes a change in my eligibility to participate in the Medicare program due to changes in
my age or disability status or my enrollment in Medicare Part D.
•
Not to attempt to claim or submit any costs associated with the medicine(s) I receive under the Johnson & Johnson Patient Assistance
Foundation, Inc. Patient Assistance Program to any person or entity, including my Medicare Part D plan.
•
Not to seek true out-of-pocket (TrOOP) credit under the Medicare Part D program for the cost of the medicine(s) I receive under this program.
I authorize the following communications:
•
Specically, I authorize JJPAF to contact me to request my assistance with analysis related to the quality and efcacy of the JJPAF Program.
•
When signing this application, I am agreeing to allow the manufacturer or its agent to contact me or my healthcare provider for
additional information, if needed, to evaluate any adverse event or product complaint I or my provider reported on my behalf.
•
The Program to contact my insurer, other potential funding sources, including the Centers for Medicare and Medicaid Services,
social workers, or patient advocacy organizations on my behalf in order to determine if I am eligible for health insurance coverage
or other funds, and disclose to them information contained in my JJPAF Program application or information about my prescribed
medications and medical condition that has been provided by my physician, healthcare provider, or pharmacist.
I understand that JJPAF and the vendors associated with administrating the Program (collectively the “Program
Administrators”):
•
Reserve the right without notice to change the application form, change the Program or Program criteria, or terminate my enrollment
at any time, without notice.
•
May request and obtain information about my or my family’s income.
Patient Authorization To Share Health Information: By signing on page 2, I hereby authorize:
•
My doctor(s), pharmacy and other healthcare providers, and my health plan or insurers (“Entities”) to disclose to and share with JJPAF,
the Program Administrators and their afliates, agents, contractors, representatives, service providers, and assignees (“JJPAF Recipients”),
my individually identiable health information, which may include my full name, demographic information, nancial information, and
information related to medical condition, treatment, care management, health insurance and benets, medication history, and prescriptions
(collectively, “Health Information”), whether in written or verbal form, including portions of my medical record.
•
The JJPAF Recipients to access, obtain, use, disclose, receive, and maintain my Health Information for purposes of processing this Application,
verifying the information provided in this Application, assisting in the identication of or determining eligibility under the Program and other
patient assistance resources, investigating and verifying my insurance benets, coordinating the dispensing and delivery of medication,
and conducting the additional services described above and to run the Program, including internal business purposes.
In addition, by signing on page 2, I understand and agree that:
•
I may refuse to sign the form on page 2. This authorization is voluntary, but if I refuse to sign this form, I know that this means that I may
no longer be eligible to receive assistance from the Program. I understand that my doctor(s), pharmacy and other healthcare providers,
and my health plan or insurers may not condition the provision of my treatment, or coverage of my benets, on my signing this authorization.
•
Health Information released under this authorization may no longer be protected by state and federal law, including the Health
Insurance Portability and Accountability Act (HIPAA).
•
The information provided in this application may be subject to random audits and verication, and that during such audits and
verication processes, I may be asked for additional supporting documentation and will comply with such requests.
•
I may withdraw my authorization at any time by mailing a written withdrawal to JJPAF at PO Box 0367, Chestereld, MO 63006,
however, such withdrawal will not have an impact on any actions that have already been taken in reliance on this authorization.
•
This authorization will last until I am no longer participating in the Program or sooner as limited by applicable state law.
•
I have a right to receive a copy of this authorization.
Patient Assistance Program Application
DO NOT SUBMIT THIS PAGE—IT IS FOR PATIENT AND HEALTHCARE PROFESSIONAL RECORDS ONLY
Revised: August 2020*See full U.S. prescribing information, including Black Box warning.
© Johnson & Johnson Patient Assistance Foundation, Inc. page 5 of 5
HEALTHCARE PROFESSIONAL AUTHORIZATION: JJPAF POLICY AND TERMS & CONDITIONS AGREEMENT
Please read, sign and date on page 3, HCP Section 3.
Johnson & Johnson Patient Assistance Foundation, Inc. (JJPAF) policy prohibits Healthcare Professionals
(HCPs) from charging patients any fee for enrollment or other activities associated solely with the patient’s
participation in the Patient Assistance Program (“Program”).
•
JJPAF requests that HCPs not charge the patient for those professional services associated with this regimen not covered by the
patient’s health insurer.
•
No claim may be made to any third-party payer (e.g., Medicaid, Medicare, private insurance, etc.) for payment for product provided
under the Program.
•
In accordance with the CMS Medicare Policy Manual, CMS will not reimburse you for any free product donated from JJPAF. In
addition, in accordance with our eligibility criteria, Medicare Part B patients may receive free physician-administered product from
JJPAF when such product is not covered by CMS. In such a case, and according to CMS policy, claims for administration services
may not be reimbursed. You accept product from JJPAF with this understanding.
•
The products(s) provided under the Program may not be sold or traded and may not be returned for credit.
•
The JJPAF Program is limited to patients being treated on an outpatient basis.
•
JJPAF and the vendors associated with administrating the Program (collectively, the “Program Administrators”) reserve the right
to request additional information if needed and to change or terminate the Program at any time, without notice.
•
JJPAF and the Program Administrators reserve the right to refuse to distribute the medications under this program to any patient
or facility at any time, without notice.
Indicate your agreement to the terms of the JJPAF Program participation by signing on page 3. Your signature
is intended to conrm to JJPAF:
•
There is a valid medical need for this patient’s prescription.
•
I authorize JJPAF or its afliated companies or subcontractors to forward the patient’s prescription to a dispensing pharmacy on
behalf of the patient.
•
I authorize JJPAF to use my provider information, including National Provider ID # to determine a patient’s eligibility in the Program.
•
That to the best of your knowledge this patient does not have prescription drug insurance coverage for the product(s) listed above.
•
For SIRTURO
®
, if the patient has been diagnosed with pulmonary multi-drug resistant tuberculosis (MDR-TB), appropriate notication
has been made to the local (state) health department.
•
For SPRAVATO
®
*, the healthcare setting will be certied in the SPRAVATO
®
Risk Evaluation and Mitigation Strategy (REMS) and
the patient will be enrolled in the SPRAVATO
®
REMS. SPRAVATO
®
will not be dispensed directly to this patient for home use.
•
You are not prohibited from participating in Federally funded healthcare programs nor are you on the List of Excluded Individuals/
Entities maintained by the HHS Ofce of Inspector General.
•
That the medication(s) provided to you by the Program will not be provided or dispensed to any other person.
•
I have a signed copy on le of my patient’s current and completed patient authorization to share health information in accordance
with HIPAA, or any other authorization or consent required by law, so that you may share patient health information with the Program,
including the JJPAF Recipients.
•
I understand that the information provided in this application may be subject to random audits and verication and that, during such
audits and verication processes, I may be asked for additional supporting documentation and will comply with such requests.
Patient Assistance Program Application
DO NOT SUBMIT THIS PAGE—IT IS FOR PATIENT AND HEALTHCARE PROFESSIONAL RECORDS ONLY
Revised: August 2020*See full U.S. prescribing information, including Black Box warning.
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Completed 31 July 2020

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