JOB#: 96421
VERSION: R3
DATE: 3/22/2016
CUSTOMER: FIS (IL)
JOB NAME: Janssen CarePath/Simponi Aria(TrialCard) - 37442C0
ISSUER: TrialCard, Inc.
P.O. #: 112378
PREVIOUS JOB #:
QUANTITY: 121000
SHIP VIA: BrinksTT
SHIP TO: FIS - IL - IL
Savings Program
Valid in US and US Territories
Please call 888-535-1981 for ca
Limited Use Rebate Card
for commercially insured patients
Pay just $5 per infusion*
CARD TYPE: MasterCard Debit
CARD CONSTRUCTION: F4100 100% PVC Opaque White (Spl
CARD SIZE: 2-1/8" X 3-3/8"
CORE: White 14 mil
FINISH: Polish/Polish
COLOR TARGET: Proof
*$20,000 maximum program benefit per calendar year.
Not valid for patients
using Medicare or Medicaid.
BIN: 543103
EMBOSS POSITION:
See eligibility
requirements on back.
ICA: 8908
No cash access
VOID
VOID
5431 03XX
0312 XXXX
3456 7890
5431
XXXX
VALID
VALID
THRU
THRU
11/19
ID 12345678910
BIN 610020
GRP 99992288
STOCK #: 37442C004
ID #: 112378/37442C004
MAG STRIPE: 2-Track Hi-Co Uncoated Overlay
SIG PANEL TYPE: MC FIS IL 2.81x.406 CVC2
HOLOGRAM: MasterCard Debit Hologram
HOLOGRAM LOCATION: Holo (Front)
HOLOGRAM PREMIUM:
FRONT
4 Color Process,MC Red, MC Yellow, U.V.
Get savings off your deductible, co-pay, and co-insurance medication costs for SIMPONI ARIA®.
3 ways to enroll and
get a card if you
don’t have one
MODULE TYPE:
MODULE SIZE:
INLAY:
PRE PERSO:
KEY ID:
KMCID:
Expiration Details:
This is a prepaid card issued by MetaBa
will not earn any interest on the funds.
law, taxed, or restricted. Not valid for p
the right to rescind, revoke, amend, ter
provided on back of Savings Program b
cards or misuse of cards. Patients: Cal
BENEFIT process a COB/split bill claim u
5431
Black
This order
does not contain any embossing effect on the printed product. F
1 Enroll and activate your
card
PDF/Proof demonstrating the impact the embossing will have on the existi
appearance, a design adjustment may be necessary, please check with yo
representative.
NOTES:
BY APPROVAL OF THIS PROOF, CUSTOMER ACCEPTS FULL
RESPONSIBILITY FOR THE CONTENT OF THE CARD
Online
Phone ADDITIONAL
INCLUDING TEXT, GRAPHICS, CONSTRUCTION,
VISUALS, TECHNOLOGY SPECIFICATIONS,
AND AGREES TO
SimponiAria.JanssenCarePathSavings.com
877-CarePath
(877-227-3728)
ALL THE TERMS SET FORTH
ON THIS PROOF.
Fax or Mail
Complete Patient Enrollment Form†
If you can read this, your Adobe Acrobat display settings must be adjusted to properly view this proof. Please follow these instructions:
Open the proof in Adobe Acrobat. Click on Edit in the tool bar along the top, and go to Preferences/Page Display.
You will see a selection that says “Use Overprint Preview.” The selection in the box must say “Always.”
You now should be able to view the PDF correctly. If you are using a program other than Adobe Acrobat,
please let us know and we will provide instructions to correct the display settings.
†You will activate
your card upon receipt
APPROVED
as submitted
of enrollment
confirmation
mail.
Make Alterations,
send
me a new by
hard
copy
CUSTOMER APPROV
Make Alterations, Email me a new PDF
Once activated, you can use
card to save
onlocation
your and
eligible
medication costs
forgraphics,
SIMPONI
ARIA®.
Thisyour
proof represents
the exact
spellingout-of-pocket
of text and the appearance/location
of all type,
color(s)
(except when foil or clear core is used), sig
chip module, except that the actual design and appearance of a smartcard chip module can vary depending on the module manufacturer. If any changes ne
notes
section (noton
on the
physical
proof). CPI
will submit
a proof
the appropriate
association for approval, as required. It is the issuer’s responsibility to obtain A
How your card can be used
depends
the
insurance
you
use to
paytofor
your medication:
ship and invoice ±10 percent of the quantity ordered (±20% on orders of 500 or less). CPI will maintain maximum variations (within 2 standard deviations) of 2.0
and 3.0 dE press-to-proof during a press run. Production will not begin until a signed approved proof, without alterations, is returned to CPI. CPI will not be liable
If you
use
your
pharmacy/prescription
insurance
to
• If you use your medical/primary
to paythat
forwere
yournot included in•the
signed proof. insurance
Alterations or changes
artwork
or the
original
instructions from customer will be
subject to additional
charges and
pay for
your
medication
from
a specialty
pharmacy,
medication through yourNOTWITHSTANDING
doctor, infusion
provider,
or CONTRARY:
a specialty
ANYTHING
TO THE
(A) IN NO EVENT
WILL
CPI CARD
GROUP, INC.
OR ANY
OF ITS SUBSIDIARIES
BE RESPONSIBLE FOR
PUNITIVE DAMAGES; AND (B) IF THROUGH OUR FAULT (NOTE: ERRORS ON AN APPROVED PROOF ARE NOT OUR FAULT) THE PRODUCT IS DEFECTIVE, CPI
you
may
be
able
to
use
your
card
for
instant
savings.
pharmacy, you may be able
to
use
your
card
to
receive
a
rebate.
THE PRODUCT OR TO REFUND THE MONEY YOU PAID FOR THE DEFECTIVE PRODUCT, ALL AT CPI’S OPTION, WHICH WILL BE YOUR SOLE REMEDY. IN NO
REPLACEMENT OF ANY CARDS, PARTS, COMPONENTS OR SUPPLIES PROVIDED BY YOU. CPI WILL NOT BE RESPONSIBLE FOR REPLACING ANY PRODUCT
Your card is not a credit card. There is no charge for your card.
Before the calendar year ends, you will receive information and eligibility requirements for continued participation in the program.
2 Create your online account
Manage your savings program benefits
Get started now…
•Review your available benefit
•Submit rebate requests online, if needed
•View rebate funds available on your card
•Receive timely alerts and program updates
Visit SimponiAria.JanssenCarePathSavings.com
Need Call 877-CarePath (877-227-3728)
help? Monday–Friday, 8:00 am–8:00 pm ET
3 Use your card for savings on your medication (see next page)
Janssen Biotech, Inc., the maker of SIMPONI ARIA®, is not liable for unintended or unauthorized use of the SIMPONI ARIA® MasterCard® if it is lost or stolen. The Janssen CarePath Savings Program
for SIMPONI ARIA® Prepaid MasterCard is issued by MetaBank®, Member FDIC, pursuant to license by MasterCard International Incorporated. MasterCard is a registered trademark of
MasterCard International Incorporated. Janssen CarePath Savings Program is not a MetaBank product and is not endorsed by them.
Please read the full Prescribing Information, including Boxed Warnings and Medication Guide, for SIMPONI ARIA® and discuss
any questions you have with your doctor.
3 Use your card for savings on your medication
If you use your medical/primary insurance
to pay for your medication:
If you use your pharmacy/prescription
insurance to pay for your medication:
1. Your provider or specialty pharmacy collects your co-pay.
2. You receive infusion treatment with SIMPONI ARIA® (golimumab).
Your provider or specialty pharmacy submits the claim to your
insurance company.
3. You and your provider receive an Explanation of Benefits (EOB)
statement from your insurance company.
•You or your provider submit the EOB to Janssen CarePath Savings
Program (see How to submit a rebate request below).
4. Janssen CarePath Savings Program reviews your EOB, and issues
your rebate to your card, if eligible.
5. Once funds are available on your card, you can use it at your
provider’s office for your infusion, or with the specialty pharmacy.
Remember to bring your card to your infusion appointment.
If your provider or specialty pharmacy does not accept
SIMPONI ARIA® MasterCard®, you will receive a rebate check.
You may request check to be sent directly to your provider.
The specialty pharmacy will call to collect your co-pay.
Use your card to receive instant savings off the cost of
your medication.
OR
If the specialty pharmacy is unable to process your
card for instant savings, you may still be able to receive
a rebate:
• Complete and submit the Rebate Form‡ along with your
pharmacy receipt, to Janssen CarePath Savings Program
(see How to submit a rebate request below).
• You will receive a rebate check, if eligible.
‡A Rebate Form is only required when submitting a specialty
pharmacy receipt. It is not required when submitting an EOB.
How to submit a rebate request
Please confirm with your provider if you or your provider will submit the request.
It’s your choice. If you have created an online account, you can submit rebate requests online. You can also submit by fax or by mail:
Online:
SimponiAria.JanssenCarePathSavings.com
Am I eligible?
Fax:
855-820-3224
Mail:
Janssen CarePath Savings Program
2250 Perimeter Park Drive, Suite 300
Morrisville, NC 27560
You may be eligible for the Janssen CarePath Savings Program if you currently use private or commercial health insurance to cover a portion
of medication costs for SIMPONI ARIA®. There is no income requirement.
Janssen CarePath Savings Program for SIMPONI ARIA® is based on medication costs only and does not include costs to give you your infusion.
Other requirements
• This offer may not be combined with any other coupon, discount, prescription savings card, free trial, or other offer.
• This program is only available to individuals using private or commercial health insurance to cover a portion of their medication costs, including plans available
through state and federal healthcare exchanges. This program is not available to individuals who use any state or federal government-subsidized healthcare
program to cover a portion of medication costs, such as Medicare, Medicaid, TRICARE, Department of Defense, or Veterans Administration. Patients confirm that
they will not seek reimbursement from any of these programs or from pharmaceutical patient assistance foundations and accounts such as a Flexible Spending
Account (FSA), Health Savings Account (HSA), or Health Reimbursement Account (HRA).
• The selling, purchasing, trading, or counterfeiting of this card is prohibited.
• Offer good only in the United States and Puerto Rico. Janssen Biotech, Inc., reserves the right to rescind, revoke, or amend this offer without notice at any time.
Void where prohibited, taxed, or otherwise restricted by law.
• Offer for new enrollment expires December 31, 2017. For Massachusetts residents only, this offer is subject to change per state legislation.
• Before you activate your card, it is important that you understand that you will be asked to provide personal information that may include your name,
address, phone number, email address, and information related to your insurance and treatment. This information is necessary to permit
Janssen Biotech, Inc., the maker of SIMPONI ARIA® and companies that work with Janssen Biotech, Inc., including our affiliates and our service providers,
to fulfill your request to enroll in the Janssen CarePath Savings Program. We may also use the information you give us to learn more about the people who
use SIMPONI ARIA®, and to improve the information we provide to people who are being treated with SIMPONI ARIA®. Janssen Biotech, Inc., will not
share your information with anyone else except as required by law.
• As a condition of participating in this program, you must ensure that you comply with any co-payment disclosure requirements of your insurance carrier or
third-party payer, including disclosing to your insurer the amount of co-payment support you receive from this program.
• This program is not retroactive.
Janssen CarePath is in no way an extension of medical treatment provided by healthcare professionals to individual patients.
You may discontinue your participation at any time by calling 877-CarePath (877-227-3728).
Please read the full Prescribing Information, including Boxed Warnings and Medication Guide, for SIMPONI ARIA®
and discuss any questions you have with your doctor.
© Janssen Biotech, Inc. 2016 6/16 043284-151112