Our Co-Pay Support Program

We will not collect personal information when you download an ELMIRON® Savings Card. When you first use the card, Johnson & Johnson Health Care Systems Inc., our affiliates, and our service providers will use your personal information to determine your eligibility for the savings program, and to provide benefits to you related to the use of the savings card. Our Privacy Policy governs the use of information you provide.

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.

PATIENTS WITH COMMERCIAL INSURANCE:

Eligible patients using commercial or private insurance can save on out-of-pocket costs for ELMIRON® (‍pentosan polysulfate sodium‍)‍.

Eligible patients pay as little as $25 per fill. There is a $300 limit for each 30-day supply and a maximum program benefit of $3,600 per calendar year. 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. Offer subject to change or end without notice.

There is no income requirement. See program requirements below.

        PATIENTS WITHOUT COMMERCIAL INSURANCE:

        If you don’t have prescription drug coverage, find out more about assistance programs that could provide discounted or free prescriptions at JNJwithMe.com.

              PROGRAM REQUIREMENTS:

              Am I eligible?

              You may be eligible for the ELMIRON® EarlyAssist™ Savings Card if you use commercial or private health insurance for your prescribed ELMIRON®, and must pay an out-of-pocket cost for your medicine. Participate without sharing your income information.

              Some health plans have programs or benefit designs known as “accumulators” or “maximizers.” These programs divert patient assistance funds away from patients.

              You may be eligible for ELMIRON® EarlyAssist™ if you use private or commercial health insurance for ELMIRON®.

              • Accumulators don’t allow patient assistance to count toward the patient’s deductible and out-of-pocket maximum until the maximum value of the patient assistance is reached.
              • Maximizers also don’t allow patient assistance to count toward the patient’s deductible and out-of-pocket maximum. Maximizers apply the full value of the patient assistance over the year. This could be either the same amount each month or a larger amount early in the year that tapers off, without allowing any of those funds to count toward the patient’s annual deductible or out-of-pocket maximum.
              • The ELMIRON® EarlyAssist™ Savings Card is designed solely for the benefit of the patient. Thus, Johnson & Johnson reserves the right to reduce the ELMIRON® EarlyAssist™ Savings Card maximum benefit for patients in an accumulator or maximizer program or benefit design, except where prohibited by law.

              In addition, some health plans have “non-essential health benefit maximizers” that conflict with the program requirements of the ELMIRON® EarlyAssist™ Savings Card.

              • These programs or benefit designs, like the services offered by SaveOnSP, classify certain specialty medicines such as ELMIRON® as “non-essential.” This takes away protections for patients provided by the Affordable Care Act (ACA) related to maximum out-of-pocket limits.
              • The ELMIRON® EarlyAssist™ Savings Card is designed solely for the benefit of the patient. If your insurance company or health plan partners with SaveOnSP, then except where prohibited by law, you will not be eligible for, and you agree not to use, the ELMIRON® EarlyAssist™ Savings Card.
              • J&J reserves the right to discontinue cost support if you no longer meet eligibility requirements.
              • If your health plan removes ELMIRON® from its partnership with SaveOnSP or other non-essential health benefit maximizer, you may be eligible to be reinstated in the ELMIRON® EarlyAssist™  Savings Card.

              By utilizing this Savings Card, you accept and agree to abide by these Savings Card requirements. Any individual or entity who enrolls or assists in the enrollment of a patient in the Savings Card represents that the patient meets the eligibility criteria and other requirements described.

              Other requirements

              • The ELMIRON® EarlyAssist™ Savings Card is only for people using commercial or private health insurance who must pay an out-of-pocket cost for their prescribed ELMIRON®. This includes plans from the Health Insurance Marketplace. The ELMIRON® EarlyAssist™ Savings Card is not for people who use any state or federal government-funded healthcare program. Examples of these programs are Medicare, Medicaid, TRICARE, Department of Defense, and Veterans Administration.
              • By enrolling in the ELMIRON® EarlyAssist™ Savings Card, you agree that this Savings Card is intended solely for the benefit of you, the patient. You may not seek payment for the value received from the ELMIRON® EarlyAssist™ Savings Card from any health plan, patient assistance foundation, flexible spending account, or healthcare savings account.
              • You must meet the ELMIRON® EarlyAssist™ Savings Card requirements every time you use the card.
              • Terms will expire at the end of each calendar year. The ELMIRON® EarlyAssist™ Savings Card may change or end without notice, including in specific states.
              • ELMIRON® EarlyAssist™ Savings Card participants are subject to an annual maximum benefit. Savings Card benefits are set at the discretion of J&J and may change without notice.
              • Patients who are subject to programs, health plans, or benefits that claim to reduce their patients’ out-of-pocket co-pay, co-insurance, or deductible obligations for certain prescription drugs based upon the availability of, or patient’s enrollment in, manufacturer-sponsored co-pay assistance for such drugs will be subject to a reduced annual maximum program benefit per calendar year (not applicable to patients in Maine).
              • Patients who are subject to programs, health plans, or benefits that claim to eliminate their out-of-pocket costs are not eligible for the ELMIRON® EarlyAssist™ Savings Card, because this Savings Card is only for people who must pay an out-of-pocket cost for ELMIRON®.
              • Notwithstanding any other term of this Savings Card, patients who are members of health plans that partner with SaveOnSP, or who are subject to services administered by SaveOnSP, are not eligible for the ELMIRON® EarlyAssist™ Savings Card. If your health plan removes ELMIRON® from its partnership with SaveOnSP, you may be eligible for the ELMIRON® EarlyAssist™ Savings Card.
              • To use the ELMIRON® EarlyAssist™ Savings Card, you must follow any health plan requirements, including telling your health plan how much co-payment support you get from the ELMIRON® EarlyAssist™ Savings Card, if required. By using the Savings Program, you confirm that you have read, understood, and agree to the requirements on this page, and you are giving permission for information related to your Savings Program transactions to be shared with your healthcare provider(s). These transactions include rebates and any funds placed on the card or balance remaining on the card.
              • Before you enroll in the ELMIRON® EarlyAssist™ Savings Card, you will be asked to provide personal information that may include your name, address, phone number, email address, and/or other information, including information related to your prescription medicine insurance and treatment. This information is needed for Johnson & Johnson Health Care Systems Inc. and our service providers to enroll you in the ELMIRON® EarlyAssist™ Savings Card. The use of your information will be governed by our Privacy Policy.
              • This offer may not be used with any other coupon, discount, prescription savings card, free trial, or other offer. Offer good only in the United States and its territories. Void where prohibited, taxed, or limited by law.
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