ELMIRON® (pentosan polysulfate sodium) Capsules
(pentosan polysulfate sodium) Capsules
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ELMIRON® (pentosan polysulfate sodium) Capsules
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Need help paying for your ELMIRON® (pentosan polysulfate sodium) Capsules prescription?

We want to guide you to programs that may help. Here you'll find the financial assistance programs available for ELMIRON®. We have also listed most of the eligibility requirements for each, so you can narrow your focus to those that best suit your circumstances. Call the programs or visit their websites to learn more.

To view programs that are best suited for you, select your insurance status for ELMIRON® or view all assistance programs

You may be eligible for one or more of the following programs:

To view programs that are best suited for you, select your insurance status for ELMIRON® or view all assistance programs

You may be eligible for one or more of the following programs:

At the current time, patient affordability programs for the selected insurance option are not available for this product. Please check back, as programs change.

The following programs are affiliated with Janssen.

They are updated on a regular basis. Be sure to visit the program site for additional information.

ELMIRON® EarlyAssist™ Savings Card

This program is an instant savings card that reduces your out-of-pocket expenses by up to $35 per month for up to 4 months per calendar year. You are required to pay an initial $5 out-of-pocket cost to receive UP TO $35 off your co-payment or cash payment each time you fill your monthly prescription for ELMIRON®, for UP TO 4 total uses by December 31, 2016. The card is limited to one (1) per patient and is not transferable.

You may be eligible if:

  • You have been prescribed ELMIRON® for an FDA-approved use
    AND
  • Your prescription is not covered and/or reimbursed by a federal healthcare program, including Medicare, Medicaid, TRICARE, or any other federal or state healthcare plan.
  • You use the card only in the United States.
View application requirements

Application Requirements for ELMIRON® EarlyAssist™ Savings Card

To apply, you'll need to have:
  • Your prescription
  • A printed version of the EarlyAssist™ Savings Card

Any eligible reduction of your out-of-pocket expenses should take place immediately upon checkout.

The following programs are not affiliated with Janssen.

Be sure to contact the programs directly to get details on eligibility and application requirements, and to see if they have funding available to help you.

Johnson & Johnson Patient Assistance Foundation

Johnson & Johnson Patient Assistance Foundation, Inc. (JJPAF) provides free prescription medications to eligible individuals who do not have insurance coverage for their medicines and do not have adequate financial resources to pay for them. Please contact a JJPAF program specialist at 800-652-6227 (9 AM to 6 PM ET) or visit the foundation website at JJPAF.org to see if you might qualify for assistance.

State-Sponsored Programs

Some states sponsor prescription financial assistance programs, each with its own eligibility requirements.

Find out if your state has a program that can help you »

Medicare Savings Program

Many states have programs for people with limited income and resources that pay some or all of Medicare's premiums and may pay Medicare deductibles and coinsurance. Find out if your state has a program that can help you.

Medicare Part D Extra Help — Low-Income Subsidy

Medicare patients who have limited income and resources may qualify for "extra help" to pay for prescription drugs. The Low-Income Subsidy (LIS) program from Medicare provides financial assistance for patients who may otherwise be unable to afford the costs associated with their Medicare Part D plan.

Those who are eligible for LIS may:

  • Receive assistance paying their monthly premium
  • Have a reduced or no deductible
  • Have reduced or no prescription coinsurance and co-payments
  • Have no gap in coverage
July 12, 2016
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IMPORTANT SAFETY INFORMATION

INDICATION

What is ELMIRON® (pentosan polysulfate sodium)?

ELMIRON® is a prescription medication used to treat the bladder pain or discomfort associated with interstitial cystitis (IC). It is not known exactly how ELMIRON® works, but it is not a pain medication like aspirin or acetaminophen and therefore must be taken continuously for relief as prescribed by your doctor.

Tell your doctor about any side effect that bothers you or does not go away. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088 (1-800-332-1088).

Please read the ELMIRON® Patient leaflet and discuss it with your doctor.

02E10016C

IMPORTANT SAFETY INFORMATION

INDICATION

What is ELMIRON® (pentosan polysulfate sodium)?

ELMIRON® is a prescription medication used to treat the bladder pain or discomfort associated with interstitial cystitis (IC). It is not known exactly how ELMIRON® works, but it is not a pain medication like aspirin or acetaminophen and therefore must be taken continuously for relief as prescribed by your doctor.

Tell your doctor about any side effect that bothers you or does not go away. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088 (1-800-332-1088).

Please read the ELMIRON® Patient leaflet and discuss it with your doctor.

02E10016C