PsO SIMPLE TRIAL PROGRAM

The TREMFYA® PsO Simple Trial Program gives patients a no-cost starter dose of TREMFYA® in as few as 3 business days, so they can see if it's right for them.

Read about eligibility and program details in the PsO Simple Trial Program Brochure.

ACCESS FORMS

Here are all the forms you may need to help secure access to TREMFYA® for your patients.

Prescription Information and Enrollment Form

This form is the first step to understanding your patient’s insurance coverage and enrolling the patient in the PsO Simple Trial Program.

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Business Associate Agreement

Complete this Business Associate Agreement one time only to allow you to request verification of patients’ insurance benefits without requiring individual patient authorization.

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Patient Authorization

If no Business Associate Agreement is on file, you must secure patient authorization for each patient. Use this form or complete patient authorization on the Prescription Information and Enrollment Form. Janssen CarePath cannot accept any patient without an executed Business Associate Agreement or patient authorization on file.

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Janssen Link Office Enrollment Form

Enroll your office to connect with resources from Janssen CarePath and Janssen Link.

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Sample Letter of Exception

To document the request for a Payer to cover a nonformulary product or when step therapy through other treatments is required.

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Sample Letter of Medical Necessity

Sample letter to communicate that TREMFYA® is medically appropriate and necessary and should be covered and reimbursed.

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Sample Letter of Appeal

To document and request a Payer review a denied coverage determination for TREMFYA®, such as prior authorization or exception request denials.

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TREMFYA® Prior Authorization Checklist

Reminders and tips when completing prior authorizations for your patients.

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