PERFOROMIST® (formoterol fumarate) Inhalation Solution Savings Card
For eligible commercially insured patients, this Savings Card can be used to reduce the amount of their out-of-pocket expense up to a maximum of $550 per 30-day prescription. No other purchase is necessary. This offer can be used up to a total of 12 times per calendar year while this program remains in effect, with a maximum savings of $6,600 per calendar year. Valid prescription with Prescriber ID# required.
Please see full terms and conditions.
PERFOROMIST®(formoterol fumarate) inhalation solution Savings Card Terms and Conditions
This Savings Card can be used to reduce the amount of your eligible commercially insured patient's out-of-pocket expenses for Perforomist up to a maximum of $550 per 30-day prescription while this program remains in effect. No other purchase is necessary. This offer can be used up to a total of 12 times per calendar year with a savings cap of $6,600 per calendar year while this program remains in effect. Valid prescription with Prescriber ID# is required. Mylan Specialty L.P. reserves the right to amend or end this program at any time without notice.
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 its territories. Patients must have commercial insurance. This program is not valid for uninsured patients (but may be used by commercially insured patients without coverage for Perforomist) 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 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 its territories or where prohibited by law, taxed, or restricted. Absent a change in Massachusetts law, this program will no longer be valid for Massachusetts residents after January 1, 2021.
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 expenses. This program cannot be combined with any other rebate/coupon, 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 coupon 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 the 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), must be presented to your pharmacist.
Pharmacist Instructions: When you accept this Savings Card, you are certifying that you have received a valid prescription for the applicable product(s) above for an eligible patient; you have dispensed the product(s) 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
- Patient must have primary commercial coverage. 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.
- Acceptance of this savings card and your submission of claims for the Perforomist Savings Program are subject to these terms and conditions posted at www.activatethecard.com/perforomist/#tnc.
- Acceptance of this savings card and your submission of claims for the Perforomist Savings 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 Perforomist Savings Program at 800-657-7613 (8:00 AM-8:00 PM EST, Monday-Friday).
not actual card
Important Safety Information
Contraindications: Use of a LABA, including PERFOROMIST, without an inhaled corticosteroid is contraindicated in patients with asthma. PERFOROMIST is not indicated for the treatment of asthma.
Serious Asthma-Related Events: Use of long-acting beta2-adrenergic agonists (LABA) as monotherapy [without inhaled corticosteroids (ICS)] for asthma is associated with an increased risk of asthma-related death. Available data from controlled clinical trials also suggest that use of LABA as monotherapy increases the risk of asthma-related hospitalization in pediatric and adolescent patients. These findings are considered a class effect of LABA monotherapy. When LABA are used in fixed-dose combination with ICS, data from large clinical trials do not show a significant increase in the risk of serious asthma-related events (hospitalizations, intubations, death) compared with ICS alone. Available data do not suggest an increased risk of death with use of LABA in patients with COPD.
Deterioration of Disease and Acute Episodes: PERFOROMIST Inhalation Solution should not be initiated in patients with acutely deteriorating COPD, which may be a life-threatening condition. PERFOROMIST Inhalation Solution should not be used for the relief of acute symptoms, i.e., as rescue therapy for the treatment of acute episodes of bronchospasm.
Excessive Use and Use with Other LABAs: PERFOROMIST Inhalation Solution should not be used more often, at higher doses than recommended, or in conjunction with other inhaled, long-acting beta2-agonists, as an overdose may result. Clinically significant cardiovascular effects and fatalities have been reported in association with excessive use of inhaled sympathomimetic drugs.
Paradoxical Bronchospasm: As with other inhaled beta2-agonists, PERFOROMIST Inhalation Solution can produce paradoxical bronchospasm that may be life threatening. If paradoxical bronchospasm occurs, PERFOROMIST Inhalation Solution should be discontinued immediately and alternative therapy instituted.
Cardiovascular Effects: PERFOROMIST Inhalation Solution, like other beta2-agonists, can produce a clinically significant cardiovascular effect in some patients as measured by increases in pulse rate, systolic and/or diastolic blood pressure, and/or symptoms. PERFOROMIST Inhalation Solution should be used with caution in patients with cardiovascular disorders, especially coronary insufficiency, cardiac arrhythmias and hypertension.
Coexisting Conditions: PERFOROMIST Inhalation Solution, like other sympathomimetic amines, should be used with caution, especially in patients with convulsive disorders or thyrotoxicosis, and in patients who are unusually responsive to sympathomimetic amines. Doses of the related beta2-agonist albuterol, when administered intravenously, have been reported to aggravate preexisting diabetes mellitus and ketoacidosis.
Hypokalemia and Hyperglycemia: Beta-agonist medications may produce significant hypokalemia in some patients, which has the potential to produce adverse cardiovascular effects. The decrease in serum potassium is usually transient, not requiring supplementation. Beta-agonists can produce transient hyperglycemia.
Immediate Hypersensitivity Reactions: Immediate hypersensitivity reactions may occur after administration of PERFOROMIST Inhalation Solution, as demonstrated by cases of anaphylactic reactions, urticaria, angioedema, rash, and bronchospasm.
Use in Special Populations: PERFOROMIST Inhalation Solution, as with other beta2-agonists, should be used with extreme caution in patients being treated with monoamine oxidase inhibitors, tricyclic antidepressants, or drugs known to prolong the QTc interval because the action of adrenergic agonists on the cardiovascular system may be potentiated by these agents.
Drug Interactions: Beta-blockers and formoterol fumarate may inhibit the effect of each other when administered concurrently. Therefore, patients with COPD should not normally be treated with beta-blockers except under certain circumstances e.g., as prophylaxis after myocardial infarction, there may be no acceptable alternatives to the use of beta-blockers in patients with COPD.
Concomitant treatment with Xanthine derivatives, steroids, or diuretics may potentiate any hypokalemic effect of adrenergic agonists. The EKG changes and/or hypokalemia that may result from the administration of non-potassium sparing diuretics (such as loop or thiazide diuretics) can be acutely worsened by beta-agonists, so caution is advised in the coadministration.
Most Common Adverse Reactions: The most common adverse reactions (≥2% and more common than placebo) with PERFOROMIST are diarrhea, nausea, nasopharyngitis, dry mouth, vomiting, dizziness, and insomnia.
PERFOROMIST® (formoterol fumarate) Inhalation Solution is indicated for the long-term, twice-daily (morning and evening) administration in the maintenance treatment of bronchoconstriction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema.
Important Limitations for Use:
- It is not indicated to treat acute deteriorations of COPD.
- It is not indicated to treat asthma. The safety and effectiveness of PERFOROMIST Inhalation Solution in asthma has not been established.
For additional information please contact us at 800-395-3376.Click here for Full Prescribing Information.