TREMFYA withMe Delay and Denial Support
TREMFYA® (guselkumab)
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Downloadable Forms
- Business Associate Agreement
Complete a Business Associate Agreement for your practice only once. No individual patient authorizations are required. - Delay & Denial Support Reverification Guide
Use this guide to learn how to confirm your patient's eligibility for Delay & Denial Support/Janssen Link if they have previously been eligible. - Enrollment and Prescription Form
A way to find out if TREMFYA® is covered by the patient's insurance plan, including requirements for coverage or prior authorization, any out-of-pocket costs, and approved pharmacies.
Enrollment and Prescription Form (en español para Puerto Rico) - Enrollment and Prescription Form (en español para Puerto Rico) A way to find out if TREMFYA® is covered by the patient's insurance plan, including requirements for coverage or prior authorization, any out-of-pocket costs, and approved pharmacies. En español.
- Enrollment and Prescription Form for EMA A way to find out if TREMFYA® is covered by the patient's insurance plan, including requirements for coverage or prior authorization, any out-of-pocket costs, and approved pharmacies. (EMA)
- Letter of Appeal
A template to send to patients' insurance companies to help get patients on treatment. - Letter of Exception
A template that you can fill out and submit to a patient’s health insurance provider asking them to cover a medication that is not on formulary. - Letter of Medical Necessity
A template that you can fill out and submit to a patient’s health insurance provider. You may use it to explain why TREMFYA® is medically necessary for your patient. - Letter of Medical Necessity (Reverification)
A template that you can fill out and submit to a patient’s health insurance provider to explain why it is medically necessary for your patient to continue on TREMFYA®. - Patient Affordability OptionsDiscover options that can make TREMFYA® more affordable for your patients.
Patient Affordability Options (en español) - Patient Affordability Options (en español)Discover options that can make TREMFYA® more affordable for your patients. En español.
- Patient Authorization FormIndividual patient form for offices without a Business Associate Agreement.
Patient Authorization Form (en español) - Patient Authorization Form (en español)Individual patient form for offices without a Business Associate Agreement.
- Prescribing Information & Medication Guide (en español)
Product information for TREMFYA®. En español. - Resource GuideA comprehensive summary of support tools for your office to help patients start and stay on treatment.
- Savings Program Additional Co-pay Support Form
- Savings Program Overview
Eligible patients using commercial or private insurance can save on out-of-pocket costs for TREMFYA®.
Savings Program Overview (en español) - Savings Program Overview (en español)
Eligible patients using commercial or private insurance can save on out-of-pocket costs for TREMFYA®. En español. - Savings Program Rebate Form
A form the patient can submit if the pharmacy isn’t able to process the Janssen CarePath Savings Program card.
Savings Program Rebate Form (en español) - Savings Program Rebate Form (en español)
A form the patient can submit if the pharmacy isn’t able to process the Janssen CarePath Savings Program card. En español. - Savings Program Rebate Form - Accumulator Pharmacy
A form that is submitted when the pharmacy can't process the TREMFYA withMe Savings Program card or Virtual Payment Card. - Verification of Benefits Guide (Medical)
A guide to understanding the Verification of Benefits for your patient’s medical benefits. - Verification of Benefits Guide (Pharmacy)
A guide to understanding the Verification of Benefits for your patient’s pharmacy benefits.
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TREMFYA withMe Delay and Denial Support
Need Delay and Denial Support?
- Complete a benefits investigation request in the Provider Portal at JanssenCarePathPortal.com
- OR
- Download the Enrollment and Prescription Form, complete the form, and fax to Janssen at 844-322-9402.
Program Requirements
To be eligible, patient must have:
- 1 A TREMFYA® prescription for an on-label, FDA-approved indication
- 2 Commercial insurance with biologics coverage
- 3 A delay of more than 5 business days or a denial of treatment from their insurance
In addition, for patient to be eligible, Prescriber must submit:
- 4 A program enrollment form*
- 5 A coverage determination form (eg, prior authorization or prior authorization with exception) to the commercial insurance
If coverage is denied, Prescriber must also submit a Letter of Formulary Exception, Letter of Medical Necessity or appeal within 90 days of patient becoming eligible for patient to stay in the program.
Patient is not eligible if:
- 1 Patient uses any state- or federal government-funded healthcare program to cover medication costs
- Examples of these programs are Medicare, Medicaid, TRICARE, Department of Defense, and Veterans Administration
- 2 Prior authorization is denied due to missing information on coverage determination form, used for a non-FDA-approved indication, or invalid clinical rationale
Patient is eligible until commercial insurance covers the medication. Program requires periodic verification of insurance coverage status to confirm continued eligibility.
Delay and Denial Support covers the cost of therapy only—not associated administration cost. Prescriber cannot bill commercial insurance plan for any part of the prescribed subcutaneous treatment. Patient cannot submit the value of the free product as a claim for payment to any health plan. Program good only in the United States and its territories. Void where prohibited, taxed, or limited by law. Program terms may change.
*TREMFYA withMe cannot accept any information without an executed Janssen CarePath Business Associate Agreement and/or Patient Authorization on file. The Patient Authorization can be found on the Enrollment and Prescription Form or patient can create an account on MyJanssenCarePath.com and electronically sign a patient authorization there.
Participating prescribers authorize TREMFYA withMe to:
- 1 conduct a benefits investigation and confirm prior authorization requirements
- 2 provide prior authorization form assistance and status monitoring, including the exceptions and appeals processes
- 3 refer eligible patients to Wegmans Specialty Pharmacy for further program support and shipment of medication
- 4 support the transition of patients to commercial product if the medication is covered
- 5 check insurance coverage status during the program