Print and fill out the UPTRAVI® Prescription and Statement of Medical Necessity (PSMN) Form
This form allows you to get your patients started on UPTRAVI®. The PSMN Form is not optimized for mobile devices. Please print, sign, and fax to Janssen CarePath.
- Fill in the required fields so the specialty pharmacy is able to contact the patient directly.
- Option to indicate the preferred specialty pharmacy on the cover sheet.
- You must check “yes” on the enrollment form for each optional support resource available for your patient.
- Both the physician’s signature and the date are required, as well as a copy of the patient’s insurance card.
- Please check the appropriate ICD code.
- Check that the patient has signed, dated, and completed all of the required fields. Note: Enrollment in Janssen CarePath is recommended but not mandatory.
Note: An alternate form is available for Veteran Affairs (VA) patients UPTRAVI® VA Prescription and Statement of Medical Necessity Form.
Guide to the UPTRAVI® PSMN Form
This guide provides detailed instructions to help you fill out the UPTRAVI® PSMN Form.
Prescribe UPTRAVI® online through iAssist
UPTRAVI® may now be prescribed through iAssist, a web-based platform that streamlines the prescription and enrollment process. Instead of faxing individual enrollment forms and insurance information, data can be entered in one place online to minimize incomplete forms and multiple submissions.
Support for patients using commercial or private insurance to pay for medication
Janssen CarePath Oral PAH Savings Program can help eligible patients save on their out-of-pocket medication costs for UPTRAVI®. Depending on their health insurance plan, savings may apply toward co-pay, co-insurance, or deductible. Your eligible patients will pay $5 per prescription fill with a $20,000 maximum program benefit per calendar year across all oral PAH therapies in the program. Not valid for patients using Medicare, Medicaid, or other government-funded programs to pay for their medications. Terms expire at the end of each calendar year and may change. There is no income requirement. See full eligibility requirements at Uptravi.JanssenCarePathSavings.com.
UPTRAVI® Dose Adjustment Phase Guide for patients
This guide helps you set goals and expectations with patients who are starting treatment with UPTRAVI®. It can be used as a conversation tool and is available to patients to help them stay on treatment by tracking and sharing how they’re feeling with their healthcare team.
UPTRAVI® Adverse Reactions Management Tool and Titration Guide
This guide offers dosing, titration, and pill identification information to help get your patients started with UPTRAVI®, as well as adverse reaction management guidance for PAH therapies targeting the prostacyclin pathway.
UPTRAVI® Prescribing Information
The full Prescribing Information and Patient Product Information for UPTRAVI®.
