IF YOU USE COMMERCIAL INSURANCE OR PAY CASH
You may be eligible for this offer if you are insured by commercial insurance and your insurance does not cover the full cost of your prescription, or if you are not insured and are responsible for the cost of your prescriptions.
Patients who are enrolled in a state or federally-funded prescription insurance program are not eligible for this offer. This includes patients enrolled in Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DOD) programs or TriCare, and patients who are Medicare eligible and enrolled in an employer-sponsored group waiver health plan or government-subsidized prescription drug benefit program for retirees.
If you are enrolled in a state or federally-funded prescription insurance program, you may not use this savings card even if you elect to be processed as an uninsured (cash-paying) patient.
This offer is not insurance, is restricted to residents of the United States and Puerto Rico who are over 18 years of age. This offer is not valid for mail order.
Eligible commercially-insured patients with a valid prescription for DALIRESP® (roflumilast) tablets who present this savings card at participating pharmacies will pay $25 per 30-day supply if their out-of-pocket cost is more than $25. New commercially-insured patients will receive 100% off their out-of-pocket cost for the first 30-day supply. If you pay cash for your prescription, you will receive up to $100 in savings on your out-of-pocket costs that exceed $25 for each prescription. This offer is good for 12 uses, and each 30-day supply counts as 1 use. Other restrictions may apply. Patient is responsible for applicable taxes, if any. Card must be used on or before 12/31/17. If you have any questions regarding this offer, please call 1-866-459-20151-866-459-2015.
If your commercial insurance plan does not cover DALIRESP tablets, use of this offer permits your doctor or pharmacy to share limited information with certain AstraZeneca vendors to determine if additional resources may be available to you, and to act on your behalf to initiate any processes that may be necessary to access these resources.