Eligible patients using commercial or private insurance can save on out-of-pocket costs for ELMIRON® (pentosan polysulfate sodium). Eligible patients pay an initial $5 per fill at participating retail pharmacies and receive up to $50 off their out-of-pocket prescription costs, with a maximum program benefit of $200 or 4 total fills per lifetime, whichever comes first. Not valid for patients using Medicare, Medicaid, or other government-funded programs to pay for their medications. Terms expire at the end of each calendar year and may change. There is no income requirement. See program requirements below.
You may be eligible for ELMIRON® EarlyAssist™ if you use private or commercial health insurance for ELMIRON®.
- This program is only available to individuals using commercial or private health insurance for their Janssen medication, including plans available through state and federal healthcare exchanges. This program is not available to individuals who use any state or federal government-funded healthcare program to cover a portion of medication costs, such as Medicare, Medicaid, TRICARE, Department of Defense, or Veterans Administration.
- Out-of-pocket costs paid by this program may not be submitted as a claim for payment to any third-party payer, pharmaceutical patient assistance foundation, or account such a Flexible Spending Account (FSA), a Health Savings Account (HSA), or a Health Reimbursement Account (HRA).
- Your eligibility to use the ELMIRON® EarlyAssist™ Savings Card is subject to meeting the program requirements at the time of each use.
- Program terms will expire at the end of each calendar year. Program subject to change or discontinuation without notice, including in specific states.
- As a condition of participating in this program, you must ensure that you comply with any co-payment disclosure requirements of your insurance carrier or third-party payer, including disclosing to your insurer the amount of co-payment support you receive from this program. By using the ELMIRON® EarlyAssist™ Savings Card, you confirm that you have read, understood and agree to the program requirements shown on this page.
- This program offer may not be combined with any other coupon, discount, prescription savings card, free trial, or other offer. The selling, purchasing, trading, or counterfeiting of this card is prohibited. Offer good only in the United States and its territories. Void where prohibited, taxed, or otherwise restricted by law.
This program is in no way an extension of medical treatment provided by healthcare professionals to individual patients.