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Patient Assistance Information

1 Program for Ultram ER Tablets
Janssen Ortho Patient Assistance Foundation Patient Assistance Program

PO Box 221857
Charlotte, NC 28222-1857
Phone : (800) 652-6227 Ext 1
Fax: (888) 526-5168
> The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. 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.
Who Can Apply
> 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.
> 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.
Ship To
> 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.
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
Ultram ER Tablets
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form Application Form
(Requires Acrobat Reader