Program

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Program 1 of 5 Scroll down to see them all.

This program provides brand name medications at no or low cost.
Pharmaceutical Company	Johnson & Johnson Patient Assistance Foundation, Inc
Program Name	Johnson & Johnson Patient Assistance Program
Program Address	PO Box 221857 Charlotte, NC 28222-1857
Phone Number	800-652-6227, opt 1
Fax Number	888-526-5168
Medications on Program	Ultram Tablets 50mg (tramadol)
Application Forms	Johnson & Johnson Patient Assistance Program
On-line Application	No on-line application available at this time
Web Site	Click to go to program's web site
Eligibility Guidelines and Notes	The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. Medical diagnosis necessary for this program is not specified. The patient must also be a US resident. This programs helps qualified patients gain access to medications donated by the operating companies of Johnson & Johnson. Medicare LIS (Low Income Subsidy) eligible patients are not eligible to receive assistance through this program. Patients receiving benefits under a Medicare Part D prescription drug plan are not eligible to receive assistance through this program, however program eligibility exceptions for Medicare Part D enrollees based on significant financial or medical need will be considered.
Application Process	With the patient's permission, anyone concerned can call for an application. The application will be faxed out. The completed application can be faxed or mailed back. Both the patient and doctor are notified in writing of acceptance or denial.
Application Requirements	The doctor must fill out a section and sign the application. The patient must fill out a section, sign the application and attach proof of income.
Program Details	The medications are either sent to the doctor's office or the patient is sent a pharmacy card. The company automatically sends out refills. Once a year a new application with financial documentation is needed.
Last Updated	November 13, 2009

Program 2 of 5 Scroll down to see them all.

This program provides brand name medications at no or low cost.
Pharmaceutical Company	Xubex Pharmaceuticals
Program Name	Xubex Free 30 Day Medication Supply
Program Address	PO Box 1244 Winter Park, Fl 32790-1244
Phone Number	866-699-8239
Fax Number	407-671-7960
Medications on Program	Ultram Tablets 100mg, 200mg, 300mg (tramadol)
Application Forms	Not Applicable
On-line Application	No on-line application available at this time
Web Site	Click to go to program's web site
Eligibility Guidelines and Notes	Applicants with insurance are eligible. Not applicable Medical diagnosis necessary for this program is not specified. US residency requirements are not specified. This program is non-need based and offers a 30 day supply of medication at no cost.Check the program's website as the medications change frequently.
Application Process	Anyone requesting assistance can call the above number to request an application be mailed or faxed out or download it from the website. The application can be faxed, mailed out or downloaded from website. The completed application should be faxed back from the doctor's office. Once the application is received, the medication will be shipped within 24 hours.
Application Requirements	The doctor must fill out a section and sign the application.
Program Details	Up to a 30-day supply is sent to the patient's home.
Last Updated	August 14, 2009

Program 3 of 5 Scroll down to see them all.

This program provides generic medications at a discount.
Pharmaceutical Company	Express Scripts Specialty Distribution Services
Program Name	Rx Outreach Medications
Program Address	PO Box 66536 St Louis, MO 63166-6536
Phone Number	800-769-3880
Fax Number	Not Applicable
Medications on Program	tramadol Tablets 50mg (Ultram)
Application Forms	Rx Outreach
On-line Application	No on-line application available at this time
Web Site	Click to go to program's web site
Eligibility Guidelines and Notes	Applicants with insurance are eligible. have an income at or below 300% of the Federal Poverty Level. Medical diagnosis necessary for this program is not specified. US residency requirements are not specified. This program is for generic medications only. Many medications are available for a fee of $20 for up to a 180 day supply. Prices vary for Tier 2 and Tier 3 medications. Please refer to the Rx Outreach website for more information.
Application Process	Anyone requesting assistance can call to request a faxed application or download it from the website. The application can be either faxed or mailed out upon request. The completed application must be mailed back. The patient is notified of eligibility for the program.
Application Requirements	The doctor needs to provide a prescription to the patient. The patient must fill out a section and sign the application.
Program Details	The medication is sent to either the doctor's office or the patient's home. The patient must contact the company to arrange for refills. Every year a new application is needed.
Last Updated	September 22, 2009

Program 4 of 5 Scroll down to see them all.

This program provides generic medications at a discount.
Pharmaceutical Company	Xubex Pharmaceuticals
Program Name	Xubex Patient Assistance Program
Program Address	PO Box 1244 Winter Park, Fl 32790-1244
Phone Number	866-699-8239
Fax Number	407-671-7960
Medications on Program	tramadol Tablets 50mg (Ultram)
Application Forms	Xubex Pharmaceutical Services
On-line Application	Link to online application
Web Site	Click to go to program's web site
Eligibility Guidelines and Notes	Applicants with insurance are eligible. The patient must have an income at or below 243% of the Federal Poverty Level. Medical diagnosis necessary for this program is not specified. US residency requirements are not specified. This is a program for generic medications only. There are fee for the medications either $20 or $30 for a 90 day supply. ($40 or $60 for a 180 day supply and $80 or $120 for a 360 day supply.)Xubex now offers a 30 day supply of some medications free of charge. Patients may apply online or print the prescription, complete and fax to the Xubex pharmacy for processing. Requests may be expedited by having the physician fax the completed form to the Xubex pharmacy.
Application Process	Anyone requesting assistance can call to request a faxed application or download it from the website. The application will be faxed out. The completed application can be faxed or mailed back. The medication is shipped within 10 business days.
Application Requirements	The doctor needs to provide a prescription to the patient. The patient must fill out a section and sign the application.
Program Details	The medication is sent to either the doctor's office or the patient's home. The company automatically sends out refills. Once a year a new application with financial documentation is needed.
Last Updated	August 14, 2009

Program 5 of 5.

This is a discount card program.
Pharmaceutical Company	Together Rx Access
Program Name	Together Rx Access
Program Address	PO Box 9426 Wilmington, DE 19809-9944
Phone Number	800-444-4106
Fax Number
Medications on Program	Ultram Tablets 50mg (tramadol)
Application Forms	Together Rx Access
On-line Application	No on-line application available at this time
Web Site	Click to go to program's web site
Eligibility Guidelines and Notes	The patient must have no prescription coverage for any medications and have an income at or below $45000 if single, $60000 for a family of 2, $75000 for a family of 3, $90000 for a family of 4, $105000 for a family of 5 Medical diagnosis necessary for this program is not specified. The patient must also be a US resident. The patient must not be eligible for Medicare. Most cardholders save between 25%-40% on brand name prescription medications. Each card holder's savings depend on such factors as the particular drug purchased, amount purchased, and the pharmacy where purchased.
Application Process	The patient can call to get an application, apply on line, or download the application.
Application Requirements	Not applicable.
Program Details	The patient is sent a Together Rx Access prescription savings card.
Last Updated	July 31, 2009