For US Healthcare Professionals Only
YUPELRI Patient Savings Card for patients with commercial coverage

YUPELRI® (revefenacin) 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 benefit cap of $6,600 per calendar year. Valid prescription with Prescriber ID# required. Please see full terms and conditions.

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YUPELRI® (revefenacin) inhalation solution Savings Card Terms and Conditions

This Savings Card can be used to reduce the amount of your out-of-pocket expenses for YUPELRI 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 YUPELRI) 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 YUPELRI 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 June 30, 2020.

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 YUPELRI, must be presented to your pharmacist.

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 YUPELRI 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.
  • Acceptance of this Savings Card and your submission of claims for the YUPELRI Savings Card program are subject to the Savings Card Terms and Conditions posted at www.activatethecard.com/yupelri/#tnc.
  • Acceptance of this Savings Card and your submission of claims for the YUPELRI 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 YUPELRI Savings Card program at 866-255-9018 (8:00 AM-8:00 PM EST, Monday-Friday).

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 800-395-3376.

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