PERFOROMIST® (formoterol fumarate) Inhalation Solution and Formoterol Fumarate Inhalation Solution Savings Card

What is the PERFOROMIST and Formoterol Fumarate Inhalation Solution Savings Card?

PERFOROMIST (formoterol fumarate) Inhalation Solution: For eligible commercially insured patients, this Savings Card may be used to reduce the amount of their out-of-pocket costs for PERFOROMIST up to a maximum of $550 per 30-day prescription. This offer can be used up to a total of 12 times per calendar year, with a maximum savings cap of $6,600 per calendar year while this program remains in effect. Formoterol Fumarate Inhalation Solution (the authorized generic to PERFOROMIST (formoterol fumarate) Inhalation Solution): For eligible commercially insured patients, this Savings Card may be used to reduce the amount of their out-of-pocket costs for Formoterol Fumarate Inhalation Solution up to a maximum of $25 per 30-day prescription. This offer can be used up to a total of 12 times per calendar year, with a maximum savings cap of $300 per calendar year while this program remains in effect. No other purchase is necessary. Valid prescription with Prescriber ID# required. Please see full terms and conditions.

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PERFOROMIST® (formoterol fumarate) Inhalation Solution and Formoterol Fumarate Inhalation Solution Savings Card Terms and Conditions

This Savings Card may be used to reduce the amount of your out-of-pocket costs for select Viatris products identified below up to the applicable maximum savings amount as described below while this program remains in effect. No other purchase is necessary. Valid prescription with Prescriber ID# is required. Mylan Specialty L.P., a Viatris Company, reserves the right to amend or end this program at any time without notice.

PERFOROMIST (formoterol fumarate) Inhalation Solution: Out-of-pocket costs for PERFOROMIST may be covered up to a maximum of $550 per 30-day prescription. This offer can be used up to a total of 12 times per calendar year, with a maximum savings cap of $6,600 per calendar year.

Formoterol Fumarate Inhalation Solution (the authorized generic to PERFOROMIST (formoterol fumarate) Inhalation Solution): Out-of-pocket costs for Formoterol Fumarate Inhalation Solution may be covered up to a maximum of $25 per 30-day prescription. This offer can be used up to a total of 12 times per calendar year, with a maximum savings cap of $300 per calendar year.

Eligibility Requirements: This Savings Card can be redeemed only by patients or patient guardians who are 18 years of age or older and who are residents of the United States and Puerto Rico. Patients must have commercial insurance. This program is not valid for uninsured patients (but may be used by commercially insured patients without coverage for the applicable product(s) above) 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 the applicable product(s) above is covered by such government program); not valid if the patient is Medicare eligible and enrolled in an employer-sponsored health plan or prescription benefit program for retirees; and not valid if the patient's insurance plan is paying the entire cost of this prescription. This program is void outside the US and Puerto Rico or where prohibited by law, taxed, or restricted. This program is not valid for residents of Massachusetts or California.

This Savings Card is not health insurance. This Savings Card is not transferable, and the amount of the savings cannot exceed the patient's out-of-pocket costs. This program cannot be combined with any other rebate/coupon, cash discount card, free trial, or similar offer for the specified prescription. This Savings Card is not redeemable for cash.

NOTICE: Data related to your use of this Savings Card may be collected, analyzed and shared with Mylan Specialty L.P. for market research and other purposes related to assessing its savings card programs. Data shared with Mylan Specialty L.P. will be aggregated and de-identified, meaning it will be combined with data related to other savings card redemptions and will not identify you.

Patient Instructions: 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 use of this Savings Card must be consistent with the terms of any drug benefit provided by your commercial health insurer, health plan, or private third-party payer. You agree to report the use of this Savings Card to your commercial insurer if required.
  • Where required, a Savings Card and prescription drug insurance card, along with a valid prescription for the applicable product(s) above, must be presented to your pharmacist.
  • Should you begin receiving prescription benefits from any government funded program, you will withdraw from this Savings Card program.

Pharmacist Instructions: When you accept this Savings Card, you are certifying that you have received this Savings Card from an eligible patient; you have received a valid prescription for the applicable product(s) above for 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 these terms and all applicable terms and conditions. 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.
  • For commercially insured patients, input this Savings Card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable patient savings will be displayed in the transaction response. Cash Discount Cards are not valid as primary insurance under this offer.
  • Acceptance of this Savings Card and your submission of claims for the PERFOROMIST Savings Card program are subject to the Savings Card Terms and Conditions posted at www.activatethecard.com/perforomist/#.
  • Acceptance of this Savings Card and your submission of claims for the PERFOROMIST Savings Card 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 Savings Card program at 800‑657‑7613 (8:00 AM‑8:00 PM EST, Monday-Friday).