STELARA withMe Savings Program Enrollment Form
This document is the STELARA withMe Savings Program Enrollment Form designed for patients seeking assistance with their STELARA medication costs. It outlines eligibility requirements, necessary information for enrollment, and instructions for submitting. Patients can also learn how to use the STELARA Mastercard for medication payments.
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How do I fill this out?
To fill out the STELARA Enrollment Form, begin by providing all required patient information accurately. Ensure you have your insurance details ready to complete relevant sections. Once completed, submit the form via fax or mail to the designated address.
How to fill out the STELARA withMe Savings Program Enrollment Form?
1
Begin by gathering necessary patient information.
2
Fill out all required fields accurately.
3
Provide your insurance and prescription details.
4
Review the form for completeness and accuracy.
5
Submit the completed form via fax or mail.
Who needs the STELARA withMe Savings Program Enrollment Form?
1
Patients with STELARA prescriptions seeking financial assistance.
2
Individuals aged 6 and above using commercial health insurance.
3
Healthcare providers who need to submit forms on behalf of patients.
4
Patients on government health plans who are not eligible for this program.
5
Those seeking rebates and savings on their medication expenses.
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Open the STELARA Enrollment Form in PrintFriendly.
2
Click on the fields you wish to edit.
3
Make the necessary changes to personal information.
4
Once satisfied, review the form for any errors.
5
Save your changes and download the edited form.
What are the instructions for submitting this form?
To submit the STELARA Enrollment Form, you have the option to fax it to 844-250-7193 or mail it to STELARA withMe Savings Program, 2250 Perimeter Park Drive, Suite 300, Morrisville, NC 27560. Ensure all sections are completed thoroughly before submission to avoid delays. For any questions regarding submission, contact Janssen at 844-4withMe (844-494-8463) for assistance.
What are the important dates for this form in 2024 and 2025?
Important dates for the STELARA withMe Savings Program include annual renewals every calendar year and any changes in program terms that may occur. For 2024, keep an eye out for updates in program guidelines and requirements as they may change without notice. It’s essential to stay informed to ensure continued eligibility for support.
What is the purpose of this form?
The primary purpose of this form is to enroll patients in the STELARA withMe Savings Program, aimed at assisting them with out-of-pocket costs associated with their STELARA medication. The program is geared towards individuals who have commercial or private insurance but may still face high medication expenses. This form also ensures that patients understand their rights and responsibilities while participating in the program.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes name, address, contact information, and insurance details.
- 2. Eligibility Questions: Series of questions to determine eligibility for the savings program.
- 3. Prescriber Information: Details about the healthcare provider prescribing STELARA.
- 4. Patient Signature: A signature field to certify the accuracy of the provided information.
What happens if I fail to submit this form?
If you fail to submit the STELARA Enrollment Form, you may miss out on potential savings and support for your medication costs. Without your enrollment, you cannot access the benefits offered through the program. It is crucial to ensure the form is completed accurately and submitted on time.
- Ineligibility: Failure to submit may result in ineligibility for assistance.
- Missed Rebates: Without submission, any potential rebates are forfeited.
- Treatment Delay: Delays in processing your medication needs may occur.
How do I know when to use this form?
- 1. For Financial Assistance: To apply for financial help with STELARA medication costs.
- 2. For Program Enrollment: To officially enroll in the STELARA withMe Savings Program.
- 3. To Provide Required Information: To supply necessary personal and insurance details.
Frequently Asked Questions
What is the purpose of the STELARA Enrollment Form?
The form is intended for patients to enroll in the STELARA withMe Savings Program to receive financial assistance.
Who is eligible to fill out this form?
Patients aged 6 and older using commercial health insurance are eligible.
How do I submit the filled form?
You can fax or mail the completed form to the designated address provided on the form.
Can I edit the form online?
Yes, you can edit the PDF on PrintFriendly before submitting.
What if I have government-funded health insurance?
This program is not available for those with government-funded healthcare.
Will I receive a rebate for using the program?
Yes, approved participants may receive rebates for their medication costs.
Is the STELARA Mastercard a credit card?
No, the STELARA Mastercard is not a credit card and incurs no fees.
How can I contact for assistance?
You can reach out at 844-4withMe (844-494-8463) for assistance.
What do I need to enroll?
You will need your personal information and insurance details to complete the enrollment.
Can I revoke my participation in the program?
Yes, you can cancel your enrollment at any time by calling the support number.
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