ELMIRON® EarlyAssist

Program Description:

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.

 

Program Requirements:

 

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.

If you wish to participate in ELMIRON® EarlyAssist, we will not collect your personal information before you receive a card. Upon use of the card, your information will be used by Janssen Pharmaceuticals, Inc., our affiliates, and our service providers to determine your eligibility for ELMIRON® EarlyAssist, and to provide benefits to you related to the use of the ELMIRON® EarlyAssist Savings Card. We may also use the information you provide to learn more about the people who use ELMIRON® and to improve the information we provide to people who are being treated with ELMIRON®. Janssen Pharmaceuticals, Inc. will not share your information with anyone else except as required by law. Our Privacy Policy governs the use of information you provide.

I read, understand, and agree to the program requirements shown above and would like to receive an ELMIRON® EarlyAssist Savings Card.

Download and print the card and present it at a participating retail pharmacy along with a valid prescription. Your eligibility to use this card is dependent upon meeting the program requirements each time you present the card when filling your prescription.

Take the IC Symptom Questionnaire

Pelvic pain? Frequent urination? Pain during or after sex?

Treatment May Help

ELMIRON® is a prescription medicine indicated to treat bladder pain or discomfort associated with IC.

Helpful E-mail Support Program…FREE

Join the Journey to Relief ® program.  Designed especially for new users of ELMIRON®, our free e-mail support program provides you with great tips, resources, and money-saving offers.