Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Updated December 15, 2014
 

Parafon Forte DSC

Johnson & Johnson Patient Assistance Foundation, Inc. Patient Assistance Program

This program provides brand name medications at no or low cost.

Provided by: Johnson & Johnson Patient Assistance Foundation, Inc.

PO Box 221857
Charlotte, NC 28222-1857

TEL: 800-652-6227


ALT PHONE: 800-523-5870
FAX: 888-526-5168
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Johnson & Johnson Patient Assistance Foundation, Inc.-Patient Application

HIV Common Application; Johnson & Johnson

 

Medications

  • Parafon Forte DSC Tablet 500mg (chlorzoxazone)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Not specified
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Doctor's office or patient is sent card to be used at pharmacy
Delivery Time Not specified
Refill Process Automatically sent out
Limit Not specified
Re-application New application, new documentation yearly
   

Additional Information

Medicare LIS (Low Income Subsidy) eligible patients are not eligible to receive assistance through this program.

This Program participates in the CPAPA. This single common application allows uninsured HIV-positive individuals with low incomes to use one application to apply for multiple assistance programs.

IMPORTANT: Send completed CPAPA to the corresponding addresses listed for each company.

Contact program for Spanish application.