Conducting a Benefits Investigation

Get a full view of your patients’ insurance coverage to help them start treatment quickly.

The staff at REMS-certified healthcare treatment centers can conduct benefits investigations to determine coverage and cost considerations for patient access to SPRAVATO®. The treatment center can also partner with SPRAVATO withMe for support.

Once your patient is enrolled in SPRAVATO withMe, as part of the benefits investigations, we’ll evaluate:

Medical and pharmacy benefit coverage
Behavioral health organizations (BHO) and employee-subsidized plan coverage
Prior authorization requirements, followed by appeals process if needed

REMS-certified pharmacy options that are accepted by the patient’s insurance
Coding and reimbursement information, as well as appeals process
Affordability program eligibility

Information about your patients’ insurance coverage, cost support options, and treatment support is given by service providers for SPRAVATO withMe. The information you get does not require you or your patient to use any Janssen product. Because the information we give you comes from outside sources, SPRAVATO withMe cannot promise the information will be complete. SPRAVATO withMe cost support is not for patients in the Johnson & Johnson Patient Assistance Foundation.

See how SPRAVATO withMe can help your eligible patients save on treatment. Call us at 844-4S-WITHME (844-479-4846) or visit the express enrollment site to enroll your patients in the SPRAVATO withMe Savings Program.

SPRAVATO withMe is limited to education for patients about SPRAVATO®, its administration, and/or their disease, and is not intended to provide medical advice, replace a treatment plan from the patient’s doctor or nurse, or provide case management services.

Prior Authorization (PA) Process

Help simplify the Prior Authorization (PA) process to get patients on treatment quickly*

We’ll help provide information and updates about the prior authorization and appeals process.

Our team can educate you on the prior authorization process by providing:

Payer-required documentation for submissions to support patients who have medical benefits
Tracking of submissions status
Support for appeals
Prior re-authorization notifications

To help minimize timing delays and frustration due to coverage denials, SPRAVATO withMe has contracted with CoverMyMeds to offer electronic prior authorization support for pharmacy benefit access. As a result, you will be able to access your existing CoverMyMeds account and patients’ history in the SPRAVATO withMe Provider Portal. This will help give you visibility into the process and allow you to track your patients’ progress.

*We do not fill out any information that requires the medical judgment of the prescriber, and only the prescriber can determine whether to pursue a prior authorization.

Information about your patients’ insurance coverage, cost support options, and treatment support is given by the service providers for SPRAVATO withMe. The information you get does not require you or your patient to use any Janssen product. Because the information we give you comes from outside sources, SPRAVATO withMe cannot promise the information will be complete. SPRAVATO withMe cost support is not for patients in the Johnson & Johnson Patient Assistance Foundation.

What if coverage for SPRAVATO® is not authorized?

Learn more about Exceptions & Appeals

Buy-and-Bill

The buy-and-bill pathway may be appropriate for your treatment center when SPRAVATO® is commonly covered under the medical benefit.

Key considerations¹:

Treatment center is responsible for benefits investigation and prior authorization
Requires healthcare provider (HCP) to purchase SPRAVATO®
Potential manufacturer rebates
Treatment center must store products according to requirements
Inventory flexibility allows for on-demand use
Patient scheduling flexibility

Process for buy-and-bill^1-3

Document with plus sign in circle purple icon

Complete benefits investigation and prior authorization

Purchase SPRAVATO® from specialty distributor or wholesaler

Treatment center stores SPRAVATO® inventory

Medical Assignment of Benefits (AOB) may allow your treatment center to acquire SPRAVATO® through a pharmacy when SPRAVATO® is covered under the medical benefit.

Contact your Janssen Key Account Specialist to learn more.

Have questions about acquiring SPRAVATO® from an authorized Specialty Distributor? We can help!

At Janssen, we understand there's a lot that goes into setting up your treatment center for buy-and-bill. Here is some information on how to acquire SPRAVATO®.

Please see the Pathways to Acquiring SPRAVATO® through a Specialty Distributor for more information.

References:

1.Magellan Rx Management. 2016 Medical Pharmacy Trend Report™. Accessed December 14, 2020. https://www1.magellanrx.com/documents/2019/03/medical-pharmacytrend-report_2016.pdf/.

2.Drug Channels. How specialty pharmacy is penetrating buy-and-bill oncology channels. Accessed December 14, 2020. https://www.drugchannels.net/2016/07/how-specialty-pharmacy-is-penetrating.html.

3.Health Affairs website. Prescription drug briefing. Health Policy Brief. August 10, 2017. Accessed December 14, 2020. https://www.healthaffairs.org/do/10.1377/hpb20171008.000171/full.

Pharmacy

The pharmacy pathway does not require your treatment center to purchase SPRAVATO® but requires shipment coordination before each treatment session. Using the pharmacy pathway, your treatment center receives patient-specific product from a REMS-certified pharmacy and bills for associated healthcare services only.

Key considerations¹:

Treatment center is responsible for submitting reimbursement claim for healthcare services
Potential to be working with multiple pharmacies based on payer mandates
- Must be aware of forms, processes, and delivery schedules specific for each pharmacy
Treatment center stores product for limited amount of time
Inventory is patient-specific (cannot be used on another patient or restocked)
Possibility of medical benefit being adjudicated by the pharmacy
High level of coordination required between pharmacy, patient, and provider to ensure timely delivery of medication
Dosage change on day of administration may create waste/delay treatment

Process for pharmacy pathway^2,3

Document with plus sign in circle orange icon

Pharmacy completes benefits investigation and prior authorization

Pharmacy directly ships patient-named SPRAVATO® to treatment center

Treatment center holds patient-named SPRAVATO® until patient comes in for administration

As you work with a pharmacy, it is important to:

Advise your patients

Alert the patient to expect a confirmation call from the pharmacy, which may be a number they do not recognize
Be sure to answer patient questions about co-pay or pharmacy registration (patients may be required to register on the pharmacy’s portal)
Confirm the patient’s understanding of out‑of‑pocket costs

Work proactively with the pharmacy

Confirm the patient’s pharmacy options by calling the payer directly or by working with your SPRAVATO withMe Case Manager
Provide the patient’s plan and pharmacy with information required and respond to pharmacy information requests
Follow up with the patient, their plan, and pharmacy to ensure authorization is provided
Contact the pharmacy to confirm benefits verification and shipping status

Mortar and pestle with plus sign orange icon

Approximately 90% of payers mandate or prefer the use of a specific pharmacy,^4*† which may result in your practice working with multiple pharmacies.

*The use of a mandated or preferred specialty pharmacy may vary by insurance plan.
†From Janssen Market Research (January 2020) based on a review of publicly available data for 102 payers selected from the largest nationwide payers (according to lives covered) who provide coverage for SPRAVATO®. Of these 102 payers, 93 were determined to mandate or prefer the use of a specialty pharmacy.

References:

1.Pharmaceutical Strategies Group. NASP Definitions of Specialty Pharmacy and Specialty Medications. Accessed December 14, 2020. http://naspnet.org/wp-content/uploads/2017/02/NASP-Defintionsfinal-2.16.pdf.

2.Understanding specialty pharmacy management and cost control. June 2010. Accessed December 14, 2020. https://www.shrm.org/resourcesandtools/hr-topics/benefits/documents/understanding_specialty_pharmacy_management_and_cost_control_final.pdf.

3.Catizone CA. National Association of Boards of Pharmacy. White and brown bagging emerging practices, emerging regulation. April 2018. Accessed December 14, 2020. https://nabp.pharmacy/wp-content/uploads/2018/04/White-Bagging-and-Brown-Bagging-Report-2018_Final.pdf.

4.Data on file. Janssen Pharmaceuticals, Inc. Titusville, NJ.

Conducting a Benefits Investigation

Prior Authorization (PA) Process

Buy-and-Bill

References:

Pharmacy

References:

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