STELARA withMe Delay and Denial Support
Program Description
STELARA withMe offers eligible patients subcutaneous STELARA®(ustekinumab) at no cost until their commercial insurance covers the medication. See program requirements below.
Program Requirements
To be eligible, patient must have:
a subcutaneous STELARA® prescription for an on-label, FDA-approved indication
commercial insurance with biologics coverage
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:
a program enrollment form*
a coverage determination form (i.e., 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:
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
prior authorization is denied due to missing information on coverage determination form, use 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.
Participating prescribers authorize STELARA withMe to:
conduct a benefits investigation and confirm prior authorization requirements
provide prior authorization form assistance and status monitoring, including the exceptions and appeals processes
refer eligible patients to Wegmans Specialty Pharmacy for further program support and shipment of medication
support the transition of patients to commercial product if the medication is covered
check insurance coverage status during the program.
*STELARA withMe, via Janssen CarePath, 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 Benefits Investigation and Prescription Form, or patient can create an account on and electronically sign a patient authorization there