Our Co-Pay Support Program

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.

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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 an initial $5 per fill at participating retail pharmacies and receive up to $150 off their out-of-pocket prescription costs, with a maximum annual program benefit of $1,800. 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.

    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 JanssenCarePath.com.

      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 as 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.

      What is ELMIRON® (‍pentosan polysulfate sodium‍)‍?

      ELMIRON® is a prescription medicine used to treat bladder pain or discomfort associated with interstitial cystitis. It is not known if ELMIRON® is safe and effective in children under 16 years of age.

      IMPORTANT SAFETY INFORMATION

      What is the most important information I should know about ELMIRON® (‍pentosan polysulfate sodium‍)‍ Capsules?

      Serious side effects have been reported with the use of ELMIRON®, including:

      • Changes in the retina of the eye (pigmentary maculopathy). Taking ELMIRON® may be associated with pigment changes in the retina of the eye that may continue even after stopping treatment with ELMIRON®. Tell your healthcare provider including your eye doctor right away if you have any vision changes including any of these symptoms:
        • difficulty reading
        • your vision takes longer to adjust to low or reduced light
        • blurred vision

        Throughout your treatment, regular eye examinations that include retinal examinations are suggested for early detection of retinal/macular changes. Your doctor will discuss with you when to get your first eye examination and follow up exams, and whether the treatment should be continued.

      • Increased bleeding. ELMIRON® may increase bleeding. Tell your healthcare provider right away if you have any of these symptoms:
        • bruising easily
        • nosebleeds
        • bleeding gums
        • blood in your stool

        Your risk of bleeding may be increased if you take ELMIRON® along with other medicines such as:

        • warfarin sodium
        • high doses of aspirin
        • heparin
        • anti-inflammatory medicines such as ibuprofen

      Tell your healthcare provider if you are taking any of these medicines.

      Tell your healthcare provider if you are going to have surgery. Your healthcare provider may stop ELMIRON® before you have surgery.

      Talk to your healthcare provider about when to stop taking ELMIRON® and when to start taking it again.

      What should I tell my healthcare provider before taking ELMIRON®?

      Tell your healthcare provider if you:

      • have a personal or family history of eye problems of the retina
      • have a history of aneurysms
      • have problems with easy bleeding (thrombocytopenia)
      • have hemophilia
      • have gastrointestinal problems such as ulcerations, polyps, or diverticula
      • have any liver problems
      • are pregnant or plan to become pregnant. ELMIRON® should be used during pregnancy only if clearly needed. Tell your healthcare provider if you become pregnant while taking ELMIRON®. You and your healthcare provider should decide if you should continue to take ELMIRON®
      • are breastfeeding or plan to breastfeed. It is not known if ELMIRON® passes into your breastmilk. You and your healthcare provider should decide if you will take ELMIRON® or breastfeed
      • Tell your healthcare provider about all the medicines you take, including prescription and over‍-‍the‍-‍counter medicines, vitamins, and herbal supplements

      What are the possible side effects of ELMIRON®?

      ELMIRON® may cause serious side effects including:

      • changes in the retina of the eye
      • increased bleeding

      See “What is the most important information I should know about ELMIRON® (‍pentosan polysulfate sodium‍)‍ Capsules?”

      The most common side effects of ELMIRON® are:

      • hair loss
      • diarrhea
      • nausea
      • stomach pain
      • upset stomach
      • headache
      • rash
      • abnormal liver function tests
      • dizziness

      These are not all the possible side effects of ELMIRON®.

      Call your doctor for medical advice about side effects. You are also encouraged to report side effects to the FDA: visit http://www.fda.gov/medwatch or call 1‑800‑FDA‑1088. You may also report side effects to Janssen Pharmaceuticals, Inc., at 1‑800‑JANSSEN (1‑800‑526‑7736).

      How should I store ELMIRON®?

      • Store ELMIRON® at room temperature between 68°F to 77°F (20°C to 25°C).
      • Keep ELMIRON® and all other medicines out of the reach of children.

      How should I take ELMIRON®?

      • Take ELMIRON® exactly as your healthcare provider tells you to take it.
      • Take 1 capsule of ELMIRON® by mouth 3 times a day with water at least 1 hour before meals or 2 hours after meals. Each capsule contains 100 mg of ELMIRON®.
      • If you take too much ELMIRON®, call your healthcare provider right away or go to the nearest emergency room.

      Please click here to see full Prescribing Information and read the Medication Guide.

      cp-11575v5

      + Expand

      What is ELMIRON® (‍pentosan polysulfate sodium‍)‍?

      ELMIRON® is a prescription medicine used to treat bladder pain or discomfort associated with interstitial cystitis. It is not known if ELMIRON® is safe and effective in children under 16 years of age.

      IMPORTANT SAFETY INFORMATION

      What is the most important information I should know about ELMIRON® (‍pentosan polysulfate sodium‍)‍ Capsules?

      Serious side effects have been reported with the use of ELMIRON®, including:

      • Changes in the retina of the eye (pigmentary maculopathy). Taking ELMIRON® may be associated with pigment changes in the retina of the eye that may continue even after stopping treatment with ELMIRON® . Tell your healthcare provider including your eye doctor right away if you have any vision changes including any of these symptoms:
        • difficulty reading
        • your vision takes longer to adjust to low or reduced light
        • blurred vision

        Throughout your treatment, regular eye examinations that include retinal examinations are suggested for early detection of retinal/macular changes. Your doctor will discuss with you when to get your first eye examination and follow up exams, and whether the treatment should be continued.

      • Increased bleeding. ELMIRON® may increase bleeding. Tell your healthcare provider right away if you have any of these symptoms:
        • bruising easily
        • nosebleeds
        • bleeding gums
        • blood in your stool

        Your risk of bleeding may be increased if you take ELMIRON® along with other medicines such as:

        • warfarin sodium
        • high doses of aspirin
        • heparin
        • anti-inflammatory medicines such as ibuprofen

      Tell your healthcare provider if you are taking any of these medicines.

      Tell your healthcare provider if you are going to have surgery. Your healthcare provider may stop ELMIRON® before you have surgery.

      Talk to your healthcare provider about when to stop taking ELMIRON® and when to start taking it again.

      What should I tell my healthcare provider before taking ELMIRON®?

      Tell your healthcare provider if you:

      • have a personal or family history of eye problems of the retina
      • have a history of aneurysms
      • have problems with easy bleeding (thrombocytopenia)
      • have hemophilia
      • have gastrointestinal problems such as ulcerations, polyps, or diverticula
      • have any liver problems
      • are pregnant or plan to become pregnant. ELMIRON® should be used during pregnancy only if clearly needed. Tell your healthcare provider if you become pregnant while taking ELMIRON®. You and your healthcare provider should decide if you should continue to take ELMIRON®
      • are breastfeeding or plan to breastfeed. It is not known if ELMIRON® passes into your breastmilk. You and your healthcare provider should decide if you will take ELMIRON® or breastfeed
      • Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements

      What are the possible side effects of ELMIRON®?

      ELMIRON® may cause serious side effects including:

      • changes in the retina of the eye
      • increased bleeding

      See “What is the most important information I should know about ELMIRON® (‍pentosan polysulfate sodium‍)‍ Capsules?”

      The most common side effects of ELMIRON® are:

      • hair loss
      • diarrhea
      • nausea
      • stomach pain
      • upset stomach
      • headache
      • rash
      • abnormal liver function tests
      • dizziness

      These are not all the possible side effects of ELMIRON®.

      Call your doctor for medical advice about side effects. You are also encouraged to report side effects to the FDA: visit http://www.fda.gov/medwatch or call 1‑800‑FDA‑1088. You may also report side effects to Janssen Pharmaceuticals, Inc., at 1‑800‑JANSSEN (1‑800‑526‑7736).

      How should I store ELMIRON®?

      • Store ELMIRON® at room temperature between 68°F to 77°F (20°C to 25°C).
      • Keep ELMIRON® and all other medicines out of the reach of children.

      How should I take ELMIRON®?

      • Take ELMIRON® exactly as your healthcare provider tells you to take it.
      • Take 1 capsule of ELMIRON® by mouth 3 times a day with water at least 1 hour before meals or 2 hours after meals. Each capsule contains 100 mg of ELMIRON®.
      • If you take too much ELMIRON®, call your healthcare provider right away or go to the nearest emergency room.

      Please click here to see full Prescribing Information and read the Medication Guide.

      cp-11575v5