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Patient Assistance Information

 
2 Programs for Elmiron Capsules (pentosan polysulfate sodium)
 
 
Janssen Ortho Patient Assistance Foundation Patient Assistance Program

PO Box 221857
Charlotte, NC 28222-1857
Phone : (800) 652-6227 Ext 1
Fax: (888) 526-5168
Eligibility
> The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. The patient must also be a US resident. This programs helps qualified patients gain access to medications donated by the operating companies of Johnson & Johnson. Medicare LIS (Low Income Subsidy) eligible patients are not eligible to receive assistance through this program. Patients receiving benefits under a Medicare Part D prescription drug plan are not eligible to receive assistance through this program, however program eligibility exceptions for Medicare Part D enrollees based on significant financial or medical need will be considered.
Who Can Apply
> With the patient's permission, anyone concerned can call for an application. The application will be faxed out. The completed application can be faxed or mailed back.
Required
> The doctor must fill out a section and sign the application. The patient must fill out a section, sign the application and attach proof of income.
Supply
>
Ship To
> The medications are either sent to the doctor's office or the patient is sent a pharmacy card.
Note
> The company automatically sends out refills. Once a year a new application with financial documentation is needed.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Elmiron Capsules (pentosan polysulfate sodium)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader
 
 
Together Rx Access

PO Box 9426
Wilmington, DE 19809-9944
Phone : 800-444-4106
Fax:
Eligibility
> The patient must have no insurance and have an income at or below $30,000 for an individual ($60,000 for a family of four) The patient must also be a US resident.
Who Can Apply
> The patient can call to get an application, apply on line, or download the application.
Required
> Eligible people simply respond to four questions to enroll.
Supply
> Together Rx Access prescription savings card.
Ship To
> Patient's home
Note
> The patient can call to get an application, apply on line, or download the application.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Elmiron Capsules (pentosan polysulfate sodium)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader