Pharmacy Medicare Discount Program

This is a program that permits an eligible, retail pharmacy to receive a discount for eligible YUPELRI^® (revefenacin) 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 YUPELRI prescriptions dispensed to Medicare Part B beneficiaries
Accept the Terms and Conditions of the Mylan Specialty L.P.*, YUPELRI Pharmacy Medicare Discount Program Agreement
Submit Medicare Part B claims to Medicare through a Viatris-contracted Medicare Part B claim submission service (Change Healthcare or OmniSYS)*
Not be currently receiving any rebates or discounts on YUPELRI

*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 YUPELRI Pharmacy Medicare Discount Program Agreement.
*Mylan Specialty L.P. is a Viatris Company.

Enrollment Form

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

All fields are required unless otherwise noted as optional.

Retail Pharmacy Information

Retail Pharmacy Legal Name

Contact Name

NABP Number

Medicare Provider ID (NSC)

Primary Authorized Wholesaler

Retail Pharmacy DBA Name (if not applicable, state "N/A")

Contact's Title (store owner, manager, pharmacist, etc.)

DEA Number or HIN Number

NPI (National Provider Identifier) Number

Secondary Authorized Wholesaler (Optional)

Retail Pharmacy Address Information

Street Address 1

City

ZIP Code

Fax

Street Address 2 (Optional)

State

Phone Number

Email

Medicare Claims Processor (MCP) Information & Pharmacy Store Type

Chain Store**

Chain Headquarters

Independent Store

Number of Stores

Which CMS-approved accreditation organization have you been accredited by?

**If your retail pharmacy is a chain, you must complete the Mylan Specialty L.P., a Viatris Company YUPELRI Pharmacy Medicare Discount Program Agreement 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.

Indication

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YUPELRI^® inhalation solution is indicated for the maintenance treatment of patients with chronic obstructive pulmonary disease (COPD).

Important Safety Information

YUPELRI is contraindicated in patients with hypersensitivity to revefenacin or any component of this product.

YUPELRI should not be initiated in patients during acutely deteriorating or potentially life-threatening episodes of COPD, or for the relief of acute symptoms, i.e., as rescue therapy for the treatment of acute episodes of bronchospasm. Acute symptoms should be treated with an inhaled short-acting beta₂-agonist.

YUPELRI^® inhalation solution is indicated for the maintenance treatment of patients with chronic obstructive pulmonary disease (COPD).

Important Safety Information

YUPELRI is contraindicated in patients with hypersensitivity to revefenacin or any component of this product.

YUPELRI should not be initiated in patients during acutely deteriorating or potentially life-threatening episodes of COPD, or for the relief of acute symptoms, i.e., as rescue therapy for the treatment of acute episodes of bronchospasm. Acute symptoms should be treated with an inhaled short-acting beta₂-agonist.

As with other inhaled medicines, YUPELRI can produce paradoxical bronchospasm that may be life-threatening. If paradoxical bronchospasm occurs following dosing with YUPELRI, it should be treated immediately with an inhaled, short-acting bronchodilator. YUPELRI should be discontinued immediately and alternative therapy should be instituted.

YUPELRI should be used with caution in patients with narrow-angle glaucoma. Patients should be instructed to immediately consult their healthcare provider if they develop any signs and symptoms of acute narrow-angle glaucoma, including eye pain or discomfort, blurred vision, visual halos or colored images in association with red eyes from conjunctival congestion and corneal edema.

Worsening of urinary retention may occur. Use with caution in patients with prostatic hyperplasia or bladder-neck obstruction and instruct patients to contact a healthcare provider immediately if symptoms occur.

Immediate hypersensitivity reactions may occur after administration of YUPELRI. If a reaction occurs, YUPELRI should be stopped at once and alternative treatments considered.

The most common adverse reactions occurring in clinical trials at an incidence greater than or equal to 2% in the YUPELRI group, and higher than placebo, included cough, nasopharyngitis, upper respiratory infection, headache and back pain.

Coadministration of anticholinergic medicines or OATP1B1 and OATP1B3 inhibitors with YUPELRI is not recommended.

YUPELRI is not recommended in patients with any degree of hepatic impairment.

For additional information please contact us at 1-800-395-3376.