Tiotropium Bromide Inhalation Powder Capsules

Eligibility Requirements:

• Not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any state – or federally funded program. This includes
• Medicare, Medigap, Medicaid, TRICARE®, Veterans Affairs (VA} or Department of Defense (DoD} health coverage, Employer Group Waiver Plans, or where prohibited, taxed or otherwise restricted by law.
• Must be a US resident.
• Must be 18 years of age or older to redeem this offer for yourself or a minor.

Terms and Conditions:

• Offer valid for up to 12 fills.
• A commercially insured patient with plan coverage for Tiotropium bromide inhalation powder capsules may pay as little as $25. Patients without coverage will save up to the maximum benefit amount for the program
• Patient out-of-pocket costs may vary. Patient is responsible for any remaining balance after offer is applied and applicable taxes, if any.
• This co-pay card is not valid when the entire cost of a patient’s prescription drug is eligible for reimbursement from a private insurance plan or other private health or pharmacy benefit programs.
• Patient and pharmacy agree not to seek reimbursement for all or any part of the benefit received by the patient through this offer from any third party payer and are each responsible for making any required reports of use of this offer to any third-party payer who pays any part of the prescription filled.
• Valid only at participating pharmacies in the US and Puerto Rico.
• No other purchase is necessary.
• This card and offer are not health insurance.
• The selling, purchasing, trading, or counterfeiting of this offer is prohibited by law. Void if reproduced.
• Not valid with other offers. This offer has no cash value. No cash back.
• Lupin Pharmaceuticals, Inc. reserves the right to amend, revoke or terminate this offer without notice.
• By applying this offer, pharmacist is certifying that: (i) the patient meets the eligibility criteria, (ii) you have not submitted and will not submit a claim for reimbursement under any state or federally funded program for this prescription; and (iii) participation is not contrary to pharmacy agreements with third-party payers or laws or regulations applicable to pharmacies.
• Patient and pharmacist understand and agree to comply with the eligibility requirements and terms and conditions of this offer as described above.

For questions about this program, please call (347) 252-3204.

Pharmacy Instructions:

• For a patient with an eligible third party payer, submit the claim to the primary third-party payer first and then submit the balance due as a Secondary Payer COB [coordination of benefits with patient responsibility amount and a valid Other Coverage Code, (e.g. 8, 3)].
• The patient’s out-of-pocket expense will be reduced up to the maximum savings limit for the program. Valid Other Coverage Code required.
• For any questions regarding online processing please call 1-347-252-3204.