rxhelp360.org
| Drug Information | |
| Drug | Elmiron Capsule 100mg |
| Generic Equivalent | pentosan polysulfate sodium |
| Topic | Urinary |
| Program Contact Info / Application Submission | |
| Program | Johnson&JohnsonPAP |
| Company | Johnson&Johnson |
| Form | Download PDF |
| Address | PO Box 220455, Charlotte, NC 28222-0455 |
| Phone | 800-652-6227 opt 1 |
| Fax | 888-526-5168 |
| Program Details | |
| Details | The medications are either sent to the doctor�s office or the patient is sent a pharmacy card. The company automatically sends out refills. Once a year a new application with documentation is needed |
| Program Requirements | |
| Information | The doctor fills out their section and signs the application. The patient also fills out their section, signs the application and attaches proof of income. |
| Details | Insurance card required Drivers license NOT required Proof of Income required |
| Delivery of Medication | |
| Ship Time | 2-3 Weeks |
| Delivery Options | Can NOT be delivered directly to the patient Can be delivered directly to the doctor Shipped as a voucher card |
| Application Process | |
| App Process | With the patient�s permission, anyone can call and request an application. Completed applications can either be faxed or mailed back. |
| New Applications | New applications accepted Patients can apply directly to the program Doctors can apply directly to the program Advocates can apply directly to the program Can NOT apply for a new application via phone Can apply for a new application via fax Can apply for a new application via mail |
| Refills | Refills accepted Patients can NOT apply for refills Doctors can apply for refills Advocates can apply for refills Can apply for refills via phone Can apply for refills via mail |
| Re-Applications | Re-Applications accepted Patients can apply for Re-Applications Doctors can apply for Re-Applications Advocates can apply for Re-Applications Can NOT Re-Apply via phone Can Re-Apply via fax Can Re-Apply via mail |
| Appeals | Income Appeals accepted Patients can apply for Income Appeals Doctors can apply for Income Appeals Advocates can apply for Income Appeals Hardship Appeals accepted Patients can apply for Hardship Appeals Doctors can apply for Hardship Appeals Advocates can apply for Hardship Appeals Can apply for an appeal via phone Can apply via fax Can apply for an appeal via mail |
| Eligibility | |
| Eligibility | The patient cannot have prescription coverage for the medication being requested and have an income at or below 200% of the Federal Poverty Level. The must be a US resident. If a patient is eligible for Medicare, Part D but did not enroll they may still be eligible for the program, but must first be denied from the Low Income Subsidy or at least apply for the LIS. |
| Limitations | Patients are eligible if LIS is denied Patients are NOT eligible with existing prescription coverage Patients are eligible if prescription is not covered Patients are eligible if prescription coverage has been exhausted Patients are eligible if they are accepting Medicare Patients are NOT eligible if they are accepting Medicare part D Patients are eligible if the medication is not covered under Medicare Patients are NOT eligible if Medicare coverage has been exhausted |
| Appeals | |
| Conditions | Appeals will consider out-of-pocket expenses Appeals will consider total medical expenses Appeals may be made before the patient has been denied |
| Other Medications | |
| Other Medications available in this program | |
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