PERFOROMIST® Inhalation Solution
What is the PERFOROMIST® (formoterol fumarate) Inhalation Solution Co-Pay Program?
Eligible patients pay the first $25 of their co-pay for each of their prescriptions (up to 12 prescriptions) through 12/31/2017. Mylan Specialty L.P. will reduce the amount of their out-of-pocket expense up to a maximum of $50 per 30-day supply of PERFOROMIST Inhalation Solution, up to a maximum of 1 fill of a prescription per month. No other purchase is necessary.
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Terms and Conditions
This SAVINGS card can be used to reduce the amount of your out-of-pocket expense for Perforomist® Inhalation Solution up to a maximum of $50 after you pay the first $25 for a 30-day supply, up to a maximum of one fill of a prescription per month, not to exceed twelve fills of a prescription through December 31, 2017. No other purchase is necessary. Valid prescription with Prescriber ID# required.
Eligibility Requirements: This SAVINGS card can be redeemed only by patients or patient guardians who are 18 years of age or older who are a resident of the United States and its territories. Patients must have commercial insurance. Not valid for uninsured patients (except for commercially insured patients without coverage for Perforomist® Inhalation Solution) and patients who are covered by any state or federally funded healthcare program, including but not limited to any state pharmaceutical assistance program, Medicare (Part D or otherwise), Medicaid, Medigap, VA or DOD, or TriCare (regardless of whether Perforomist® Inhalation Solution is covered by such government program); if the patient is Medicare eligible and enrolled in an employer-sponsored health plan or prescription benefit program for retirees; or if the patient's insurance plan is paying the entire cost of this prescription. Void outside the US and its territories or where prohibited by law, taxed, or restricted. This program is valid in Massachusetts through June 30, 2019, unless otherwise amended or extended by Massachusetts.
This SAVINGS card is not health insurance. The SAVINGS card is not transferable and the amount of the benefit cannot exceed the patient's out-of-pocket expenses. Cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription. Mylan Specialty reserves the right to amend or end this program at any time without notice. Data related to your redemption with this SAVINGS card may be collected, analyzed, and shared with Mylan Specialty for market research and other purposes related to assessing coupon programs. Data shared with Mylan Specialty will be aggregated and de-identified, meaning it will be combined with data related to other SAVINGS card redemptions and will not identify you. The SAVINGS card is not redeemable for cash.
Patient Instructions: Present your SAVINGS card and prescription drug insurance card, along with a valid prescription for Perforomist®. By using this SAVINGS card, you acknowledge that you currently meet the eligibility criteria and that you understand and will comply with the following additional terms and conditions:
• You have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental programs for this prescription.
• Your acceptance of this offer must be consistent with the terms of any drug benefit provided by your health insurer. You agree to report the use of this SAVINGS card to your insurer if required.
Pharmacist Instructions: When you use this SAVINGS card, you are certifying that you have received this SAVINGS card from an eligible patient; you have dispensed the product as indicated; you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental programs for this prescription; and you will otherwise comply with the terms hereof. You further certify that your participation in this program is consistent with all applicable state laws and any obligations, contractual or otherwise, that you have as a pharmacy provider, and that you will report the use of this SAVINGS card to the patient's insurer if required.
• Submit transaction to McKesson Corporation using BIN #610524.
• Primary coverage must exist. Input SAVINGS card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response.
• Acceptance of this SAVINGS card and your submission of claims for the Perforomist® program are subject to the Mylan Specialty SAVINGS card Terms and Conditions posted at http://www.Perforomist.com/savings
• Acceptance of this SAVINGS card and your submission of claims for the Perforomist® program are subject to the LoyaltyScript® program Terms and Conditions posted at www.mckesson.com/mprstnc.
• For questions regarding setup, claim transmission, patient eligibility or other issues, call the LoyaltyScript® for the Perforomist® program at 800-657-7619 (8:00 AM-8:00 PM EST, Monday-Friday).
PERFOROMIST Inhalation Solution is used long-term, twice a day (morning and evening), in controlling symptoms of chronic obstructive pulmonary disease (COPD) in adults with COPD. PERFOROMIST is for inhalation use only through a standard jet nebulizer connected to an air compressor and should not be swallowed or injected.
People with asthma who take long -acting beta2 adrenergic agonist (LABA) medicines such as PERFOROMIST have an increased risk of death from asthma problems. It is not known whether LABA medicines, such as PERFOROMIST, increase the risk of death in people with COPD. Get emergency medical care if breathing problems worsen quickly, or you use your rescue inhaler medicine but it does not relieve your breathing problems.
PERFOROMIST should not be used in children.
PERFOROMIST is not for use to treat sudden symptoms of COPD and should not be used more than twice a day. Always have a short-acting beta2-agonist with you to treat sudden symptoms.
Tell your healthcare professional about all of your health conditions, including if you:
• have heart problems
• have high blood pressure
• have diabetes
• have seizures
• have thyroid problems
• have liver problems
• are pregnant or planning to become pregnant. It is not known if PERFOROMIST Inhalation Solution can harm an unborn baby.
• are breastfeeding. It is not known if PERFOROMIST Inhalation Solution passes into breast milk and if it can harm your baby.
Tell your healthcare professional about all medicines you take including prescription and nonprescription medications, vitamins, and herbal supplements. PERFOROMIST and certain medicines may interact with each other and cause serious side effects.
PERFOROMIST can cause serious side effects including:
The most common side effects of PERFOROMIST include:
- Dry mouth
- Muscle cramps
- Nausea, vomiting
- Trouble sleeping
- If your COPD symptoms worsen over time do not increase your dose of PERFOROMIST, instead call your healthcare professional.
You are encouraged to report negative side effects of prescription drugs to the FDA.
Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.