Prior Authorizations, Exceptions & Appeals
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- Insurance Coverage
- Affordability
- Treatment Support
- Forms & Guides
- Janssen CarePath Resource GuideA comprehensive summary of support tools for your office to help patients start and stay on treatment.
- Letter of Medical NecessityA template that you can fill out and submit to a patient’s health insurance provider. You may use it to explain why PREZISTA® is medically necessary for your patient.
- Patient Affordability OptionsDiscover options that can make PREZISTA® more affordable for your patients.
- Savings Program OverviewEligible patients using commercial or private insurance can save on out-of-pocket costs for PREZISTA®.
- Savings Program Rebate FormA form the patient can submit if the pharmacy isn’t able to process the Janssen CarePath Savings Program card.

Prior Authorizations, Exceptions & Appeals
In certain states, a standardized Prior Authorization (PA) form may be required for submission to a health plan along with clinical documentation. These standard forms can be used across payers.
- Most standardized PA forms are only for prescription drugs, but some states allow them for other medical services.
- Standardized PA forms may not be used by self-funded employer-sponsored health plans, Medicare Part D plans, and Medicaid fee-for-service plans.
Prior Authorization Considerations Checklist (en español)
Supporting Appropriate Payer Coverage Decisions Brochure (en español)
An exception is a request made to a patient's insurance company. It asks them to release a restriction they have placed on the healthcare provider's recommended treatment. Restrictions can include medication not in the formulary, step therapy, quantity limit, or high tier. Usually, a healthcare provider is required to send a statement explaining the medical reason for the exception.
Exception Considerations Checklist (en español)
Supporting Appropriate Payer Coverage Decisions Brochure (en español)
Appeals are actions taken by the patient or their healthcare provider. An appeal is used to challenge when the insurance company refuses to cover the patient's recommended treatment, or the level of coverage does not meet the patient’s expectations. The goal is to overturn the decision.
Appeal Considerations Checklist (en español)
Supporting Appropriate Payer Coverage Decisions Brochure (en español)
Additional information on the PA process at major payers is shown below. [1]
Click on the payer links to be taken to the payer's website.
- Prior Authorization: Pharmacy Benefit
- Specialty Medical Benefit Drugs (Search by product name)
- Prior Authorization Forms
- Formulary and Formulary Exceptions Form (Select Region)
- Injectable Drugs Requiring Prior Authorization (WA members)
- Non-Medicare Injectable Drugs Requiring Prior Authorization List (WA members)
[1] Collected in 11/21 and may change.
This information does not give advice or promise coverage or payment. Legal requirements and plan information can be updated frequently. Contact the plan for more information about current coverage, restrictions, or requirements that may apply.