To begin, we'll ask you a few eligibility questions

If you have questions, please call your Janssen CarePath Care Coordinator at
, Monday-Friday 8:00 AM-8:00 PM ET.

Learn more about the Janssen CarePath Savings Program, including full eligibility requirements.

First Name

MI (Opt.)

Last Name

Suffix (Opt.)

Date of Birth

Sex

Phone

Secondary Email (Optional)

Secondary Phone (Optional)

Address

Address Line 2 (Optional)

City

State

Zip

Were you prescribed XARELTO® 10 mg because you have recently undergone hip or knee replacement surgery?

Yes, I have been prescribed XARELTO® 10 mg because I have recently undergone hip or knee replacement surgery No, I have not been prescribed XARELTO® 10 mg because I have recently undergone hip or knee replacement surgery

Were you prescribed XARELTO® 10 mg after a recent non-surgical hospitalization?

Yes, I have been prescribed XARELTO® 10 mg due to a recent non-surgical hospitalization No, I have not been prescribed XARELTO® 10 mg due to a recent non-surgical hospitalization

Do you have commercial or private health insurance that you will use for your Janssen medication? Examples are commercial insurance from a former/current employer, government employee health insurance, or insurance you buy privately or through the Health Insurance Marketplace (Healthcare.gov).

Yes, I have commercial or private health insurance that I will use for my Janssen medication No, I do not have commercial or private health insurance that I will use for my Janssen medication

Do you agree NOT to ask any government-funded healthcare program to cover any of the Janssen medication costs? Examples are Medicare Parts A, B, C (also known as Medicare Advantage Plan), D, and Medicare Supplement, Medicaid, TRICARE, Department of Defense, or Veterans Administration.

Yes, I agree that I will NOT seek payment from any government-funded healthcare program for my Janssen medication No, I may seek payment from a government-funded healthcare program for my Janssen medication

Do you agree NOT to submit any costs paid by this program as a claim for payment to any health plan, patient assistance foundation, flexible spending account, or healthcare savings account?

Yes, I agree that I will NOT submit any costs paid by this program as a claim No, I may submit costs paid by this program as a claim

Please validate your information.

Patient's Information

First Name

Last Name

Suffix

Date of Birth

Sex

Phone

Secondary Email

Secondary Phone

Address

Address Line 2

City

State

Zip

Patient's Information

Cancel | Save

First Name

MI (Opt.)

Last Name

Suffix (Opt.)

Date of Birth

Sex

Email (Optional)

Phone

Secondary Email (Optional)

Secondary Phone (Optional)

Address

Address Line 2 (Optional)

City

State

Zip

Your patient may be eligible for a XARELTO withMe Savings Card! See program requirements.

I attest on behalf of the patient:

The patient will only use commercial insurance or private insurance to pay for their Janssen medication,
The patient will not use or seek payment for their Janssen medication from any government-funded healthcare program (eg, Medicare/Medicaid/Veterans Administration/Department of Defense), and
The patient will not submit any costs paid by this program as a claim for payment to a health plan, foundation, flexible spending account, or healthcare savings account.

By checking this box, I attest thatI meet the program requirements.

Please validate your information.

Patient's Information

First Name

Last Name

Suffix

Date of Birth

Sex

Phone

Secondary Email

Secondary Phone

Address

Address Line 2

City

State

Zip

Patient's Information

Cancel | Save

First Name

MI (Opt.)

Last Name

Suffix (Opt.)

Date of Birth

Sex

Email (Optional)

Phone

Secondary Email (Optional)

Secondary Phone (Optional)

Address

Address Line 2 (Optional)

City

State

Zip

The Janssen CarePath Savings Program is only available for individuals using commercial or private insurance for their Janssen medication. Please provide information on your commercial or private insurance.

If you don’t have commercial or private insurance, please click “Cancel” below.

Medical Insurance

Insurer

Policy#

Group#

Pharmacy/Prescription (Rx) Insurance

Insurer

BIN

Group

Member ID

PCN (Optional)

To proceed, please save or cancel your patient information.

Please call a Janssen CarePath Care Coordinator to help answer your questions and provide information on other programs that may help with Janssen medication out-of-pocket costs.

If you have any questions, please contact us at:

Monday-Friday, 8:00 AM - 8:00 PM ET.

We are sorry. Patient is not eligible for the Janssen CarePath Savings Program.

Based on the patient's birth date, the patient is not eligible for the program. Patients must be at least years old to be eligible for the Janssen CarePath Savings Program for XARELTO® (rivaroxaban).

Please call a Janssen CarePath Care Coordinator to help answer your questions and provide information on other programs that may help the patient with Janssen medication out-of-pocket costs.

If you have any questions, please contact us at:

Monday-Friday, 8:00 AM - 8:00 PM ET.

Please contact us for further assistance at:

Monday-Friday, 8:00 AM - 8:00 PM ET.

We're sorry. We are not able to complete your enrollment for the Janssen CarePath Savings Program

You may not be eligible for the Janssen CarePath Savings Program since our check of a third-party database indicates you have government coverage.

If you have commercial or private health insurance that you intend to use for this medication, please call a Janssen CarePath Care Coordinator to provide that information, mentioning code EFC. You may also contact us to help answer your questions and provide information on other programs that may help with Janssen medication out-of-pocket costs.

If you have any questions, please contact us at:

Monday - Friday, 8:00 AM - 8:00 PM ET

Are you sure you want to cancel out of this form?

Any entered information will be lost.
If you have any questions, please contact us at:

Monday - Friday, 8:00 AM to 8:00 PM ET

Enroll in the Janssen CarePath Savings Program for

XARELTO® (rivaroxaban)

To begin, we'll ask you a few eligibility questions

Patient's Savings Program Terms and Conditions

If you have questions, please call your Janssen CarePath Care Coordinator at
, Monday-Friday 8:00 AM-8:00 PM ET.

Learn more about the Janssen CarePath Savings Program, including full eligibility requirements.

Patient Information

Patient's Information

Patient's Information

Insurance Information

Medical Insurance

Pharmacy/Prescription (Rx) Insurance

To proceed, please save or cancel your patient information.

Please call a Janssen CarePath Care Coordinator to help answer your questions and provide information on other programs that may help with Janssen medication out-of-pocket costs.

If you have any questions, please contact us at:

Monday-Friday, 8:00 AM - 8:00 PM ET.

We are sorry. Patient is not eligible for the Janssen CarePath Savings Program.

Technical error during savings program enrollment,Please contact to Support Team.

We're sorry. We are not able to complete your enrollment for the Janssen CarePath Savings Program

Are you sure you want to cancel out of this form?

Enroll in the Janssen CarePath Savings Program for

XARELTO® (rivaroxaban)

To begin, we'll ask you a few eligibility questions

Patient's Savings Program Terms and Conditions

If you have questions, please call your Janssen CarePath Care Coordinator at , Monday-Friday 8:00 AM-8:00 PM ET.

Learn more about the Janssen CarePath Savings Program, including full eligibility requirements.

Patient Information

Patient's Information

Patient's Information

Insurance Information

Medical Insurance

Pharmacy/Prescription (Rx) Insurance

To proceed, please save or cancel your patient information.

Please call a Janssen CarePath Care Coordinator to help answer your questions and provide information on other programs that may help with Janssen medication out-of-pocket costs.

If you have any questions, please contact us at: Monday-Friday, 8:00 AM - 8:00 PM ET.

We are sorry. Patient is not eligible for the Janssen CarePath Savings Program.

Technical error during savings program enrollment,Please contact to Support Team.

We're sorry. We are not able to complete your enrollment for the Janssen CarePath Savings Program

Are you sure you want to cancel out of this form?

If you have questions, please call your Janssen CarePath Care Coordinator at
, Monday-Friday 8:00 AM-8:00 PM ET.

If you have any questions, please contact us at:

Monday-Friday, 8:00 AM - 8:00 PM ET.