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PHARMACY MEDICARE
DISCOUNT PROGRAM

Pharmacy Medicare Discount Program

This is a program that permits an eligible, retail pharmacy to receive a discount for eligible PERFOROMIST® (formoterol fumarate) Inhalation Solution product purchased and dispensed to Medicare Part B beneficiaries for their own use, as prescribed for the beneficiary.

What are the requirements of the retail pharmacy?

To participate in the program, the retail pharmacy must:

  • Be a Medicare Part B provider
  • Accept assignment on PERFOROMIST Inhalation Solution prescriptions dispensed to Medicare Part B beneficiaries
  • Accept the Terms and Conditions of the Mylan Specialty L.P., a Viatris Company, PERFOROMIST Pharmacy Medicare Discount Program
  • Submit Medicare Part B claims to Medicare through a Mylan Specialty L.P.-contracted Medicare Part B claim submission service (Change Healthcare or OmniSYS)*
  • Not be currently receiving any rebates or discounts on PERFOROMIST purchases

*If the Medicare Part B claim submission service that you currently use is not contracted with Mylan Specialty L.P. (Change Healthcare or OmniSYS), you will be required to provide electronic reports directly to Mylan Specialty L.P. Pharmacies must keep all utilization records (including prescription numbers, dates of service, volumes dispensed for each NDC) in compliance with the Terms and Conditions. Additional details are provided in the Mylan Specialty L.P., a Viatris Company, PERFOROMIST Pharmacy Medicare Discount Program agreement.

Enrollment Form

Mylan Specialty L.P., a Viatris Company, PERFOROMIST Pharmacy Medicare Discount Program

All fields are required unless otherwise noted as optional.

Retail Pharmacy Information

Retail Pharmacy Legal Name
Enter retailer’s name
Retail Pharmacy D.B.A Name (if not applicable, state "N/A")
Retailer DBA name of N/A required
Contact Name
Enter contact’s name
Contact's Title (store owner, manager, pharmacist, etc.)
Enter contact’s title
NABP Number
NABP number required
Must be 7 digits
DEA Number or HIN Number
DEA or HIN number required
Must start with 2 letters followed by 7 numbers
Medicare Provider ID (NSC)
Enter Medical provider ID
Must be 10 digits
NPI (National Provider Identifier) Number
Enter NPI number
Must be 10 digits
Primary Authorized Wholesaler
Enter primary authorized wholesaler
Secondary Authorized Wholesaler (optional)

Retail Pharmacy Address Information

Street Address 1
Enter retailer street address
Street Address 2 (optional)
City
Enter city
Select a state
Zip Code
Zip code required
5 digits only
Phone Number
Phone number required
Invalid Phone #
Fax
Fax number required
Invalid Fax #
Email
Email required
Please provide a valid email

Medicare Claims Processor (MCP) Information & Pharmacy Store Type

Please select the “Pharmacy Store Type” that is consistent with your MCP.

What does this mean?
What does this mean?
What does this mean?
Select pharmacy store type
Number of Stores
Enter number of stores
Number only
Select an organization
Which Medicare Part B claim submission service/clearinghouse do you use?
Select one of the above

**If your retail pharmacy is a chain, you must complete the Mylan Specialty L.P., a Viatris Company, PERFOROMIST Pharmacy Medicare Discount Program Exhibit Form with a full listing of all participating pharmacies including individual addresses, DEA or HIN and Medicare ID numbers.

By clicking on the "Submit" button below, you are certifying that you are a retail pharmacy and agree that the information you submit will be governed by our Privacy Notice.

Your Request Has Been Sent!

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Thank you for requesting enrollment in the PERFOROMIST® Pharmacy Medicare Part B Discount Program. A member of our internal team will review your submission and contact you via email with a Viatris Medicare Part B Purchase Discount Agreement. If you have any questions, please feel free to reach out to our team via medicarediscount@viatris.com or call us at 1-800-395-3376.

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IMPORTANT SAFETY INFORMATION

(the following information applies to both PERFOROMIST and its Authorized Generic)

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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.

Indication
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.