DALIRESP is for adults with severe Chronic Obstructive Pulmonary Disease (COPD) to decrease the number of flare-ups. DALIRESP is not a bronchodilator and should not be used for treating sudden breathing problems.

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IF YOU USE COMMERCIAL INSURANCE OR PAY CASH

*ELIGIBILITY

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.

TERMS OF USE

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 12/31/16. If you have any questions regarding this offer, please call 1-866-459-20151-866-459-2015.

Non-transferable, limited to one per person, cannot be combined with any other offer. Void where prohibited by law, taxed or restricted. Patients, pharmacists, and prescribers cannot seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this offer. AstraZeneca reserves the right to rescind, revoke, or amend this offer, eligibility and terms of use at any time without notice. This offer is not conditioned on any past, present or future purchase, including refills. Offer must be presented along with a valid prescription for DALIRESP tablets at the time of purchase.

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.

BY USING THIS CARD, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.

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IF YOU USE MEDICARE OR MEDICAID

ELIGIBILITY

This offer is good for eligible patients purchasing up to a 30-day supply of DALIRESP® (roflumilast) tablets and may not be used for any other product. This offer is good for the purchase of DALIRESP manufactured for AstraZeneca Pharmaceuticals LP and lawfully purchased from an authorized retailer or distributor in the United States or its territories.

This offer may be used by eligible 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. This offer may also be used by eligible patients who pay cash for their prescriptions. This offer is not insurance and is not valid for mail order, or for patients under 18 years of age. Offer not valid where prohibited by law, taxed, or restricted. Offer is not transferable, is limited to one per person, and may not be combined with any other offer. Offer must be presented along with a valid prescription for DALIRESP at the time of purchase.

Medicaid/Medicare or Cash-Paying Patients: You will receive one 30-day prescription free.

Pharmacist Instructions for a Medicare/Medicaid or Cash-Paying Patient: For reimbursement, please submit to Patient Choice. The information printed on this offer should be used when submitting for reimbursement. No claim for payment can be made to ANY Third-Party Payer for product dispensed pursuant to this offer. Not valid if reproduced.

Valid Other Coverage Code Required. For any questions regarding Patient Choice online processing, please call the Help Desk at 1-800-422-56041-800-422-5604.

Program managed by PSKW, LLC, on behalf of AstraZeneca.

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IMPORTANT SAFETY INFORMATION

What is the most important information I should know about DALIRESP® (roflumilast)?

DALIRESP can cause serious side effects. Tell your healthcare provider right away if you have any of the symptoms listed below while taking DALIRESP.

  • DALIRESP may cause mental health problems, including suicidal thoughts and behavior. Some people taking DALIRESP may develop mood or behavior problems, including thoughts of suicide or dying, attempt to commit suicide, trouble sleeping (insomnia), new or worse anxiety, new or worse depression, acting on dangerous impulses, or other unusual changes in behavior or mood
  • Weight loss. DALIRESP can cause weight loss. You should check your weight on a regular basis. You will also need to see your healthcare provider regularly to have your weight checked. If you notice that you are losing weight, call your healthcare provider. Your healthcare provider may ask you to stop taking DALIRESP if you lose too much weight

DALIRESP may affect the way other medicines work, and other medicines may affect how DALIRESP works. Tell your healthcare provider about all the medicines you take, including prescription and nonprescription medicines, vitamins, and herbal supplements.

Who should not take DALIRESP?

Do not take DALIRESP if you have certain liver problems. Talk with your healthcare provider before taking DALIRESP if you have liver problems.

What should I tell my healthcare provider before taking DALIRESP?

Before you take DALIRESP, tell your healthcare provider if you:

  • Have or have had a history of mental health problems, including depression and suicidal behavior
  • Have liver problems
  • Have any other medical conditions
  • Are pregnant or plan to become pregnant. It is not known if DALIRESP will harm your unborn baby
  • Are breastfeeding or plan to breastfeed. It is not known if DALIRESP passes into your breast milk

What are the most common side effects of DALIRESP?

The most common side effects of DALIRESP include diarrhea, weight loss, nausea, headache, back pain, flu-like symptoms, problems sleeping (insomnia), dizziness, and decreased appetite. These are not all the possible side effects of DALIRESP. Always tell your healthcare provider about any side effects that bother you or don't go away.

INDICATION

DALIRESP is a prescription medicine used in adults with severe Chronic Obstructive Pulmonary Disease (COPD) to decrease the number of flare-ups or the worsening of COPD symptoms (exacerbations). DALIRESP is not a bronchodilator and should not be used for treating sudden breathing problems.

Get Started

Please fill out the short form below to get great savings on DALIRESP. After submitting, you can start using your card right away.

AstraZeneca respects your personal health information. The information you provide may be used to send you health-related materials and to develop products, services, and programs. Certain information pertaining to your participation will be shared with AstraZeneca, the sponsor of the Program. The information shared will include the date that you filled the prescription, the quantity of medication dispensed by your pharmacist, and your savings under the Program. AstraZeneca, or third parties working on our behalf, will not sell or rent personal health information. If in the future you no longer want to receive these materials, please call 1-800-236-99331-800-236-9933.

Please visit www.azprivacynotice.com to review our Privacy Notice.

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Step 1 of 2: Get Started

 
 I use commercial insurance or pay cash
 I use Medicare or Medicaid
 
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STEP 2 OF 2: Enter Details

In order to participate in the savings program, please enter your details below.

 
 
 
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By registering today, you will receive information about DALIRESP, and may receive information about other respiratory medicines and services related to your condition.

You must be at least 18 years of age.

 Yes, I would like to receive information in the future about all AstraZeneca products, programs, and services that may be of interest to me.
 Yes, I would be willing to share my experience as a patient taking DALIRESP with an AstraZeneca representative.
 

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