Xopenex HFA® Savings Card

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 uses of the card per year.
• The card will expire after 12/31 of each calendar year. Patients will be required to return to the site and download a new card after expiration.
• Number of coupon uses per unique ID are limited; patients will require a new ID once the limit is reached.
• Valid only for a 30-day supply per fill of a single Xopenex HFA 15g inhaler (NDC 27437-056-01); offer will not scale to multiple inhalers.
• Insured patients with or without plan coverage for Xopenex HFA may pay as little as $25 for their prescription.
• Depending on plan coverage, program benefit may require at least 12-15 days between fills when covered or at least 15-21 days required between fills, if not covered.
• 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.

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)].
• 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 1-773-326-6796.