A new brochure has been developed by Janssen to help healthcare providers and their patients understand how to
request payer coverage for medically necessary drug therapies when:
• Initial requests for coverage are denied
• Patients need a product that would normally be subject to step therapy
• Patients need a product that is not routinely available within a payer’s network or service area
• Payers require healthcare providers to support prescriptions with additional information to ensure patient access to therapy
There are three primary categories of requests:
• Prior authorizations
• Coverage determinations (including exception requests)
• Appeals
Although there is no standardized process that applies across all payers, the goal is the same: clinical justification of a patient’s need and appropriateness for the therapy.