Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 3.
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Updated December 15, 2014
 

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

  • tramadol Tablet 50mg (Ultram)
  • tramadol Tablet; Extended Release 100mg, 200mg, 300mg (Ultram-ER)
 

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.


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
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Updated December 11, 2014
 

Rx Outreach Medications

This program provides medication at low cost.

Provided by: Rx Outreach

PO Box 66536
St Louis, MO 63166-6536

TEL: 888-796-1234


ALT PHONE:
FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website

 

Patient Assistance Applications

Rx Outreach Application

Rx Outreach Diabetic Supplies

Rx Outreach Refills and New Prescriptions Order Form

Rx Outreach Medication List

 

Medications

  • tramadol Tablet 50mg (Ultram)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income At or below 300% of FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must reside in the US
   

Application

Obtaining Call, download or apply online
Receiving Faxed or mailed
Returning Fax or E-Prescribe online
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Medications sent if accepted. If denied patient and doctor notified
Decision Timeframe Usually same day
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Not specified
Refill Process Company contacts patient to arrange
Limit Only limited by manufacturer's guidelines
Re-application New application yearly
   

Additional Information

Some medications are available for a fee of $20 for up to a 180 day supply.
Check the Rx Outreach website for the exact price and most current medication list.
Contact Program for Spanish Application(s)/Form(s)


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 3. Updated September 25, 2014
 

Xubex Patient Assistance Program

This program provides medication at low cost.

Provided by: Xubex

PO Box 1244
Winter Park, Fl 32790-1244

TEL: 866-699-8239


ALT PHONE: 407-478-2663
FAX: 407-671-7960
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Xubex Patient Assistance Program Registration Form

Xubex Patient Assistance Program Physician Order Sheet

 

Medications

  • tramadol Tablet 50mg ()
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income No limits
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Within 10 days
Refill Process Automatically sent out
Limit Varies per medication
Re-application New application, new documentation yearly
   

Additional Information

No proof of income is required. Check the website for the exact price.

This service is not currently available in Montana