Perforomist

Indicated For

COPD

About This Medication

# Viatris Patient Assistance Program Patient Guide: How to Get Perforomist at Low or No Cost ## About This Program The Viatris Patient Assistance Program is a medication assistance initiative designed to help uninsured and underinsured patients access Perforomist (formoterol fumarate) at no cost or reduced cost. Perforomist is a long-acting beta-2 agonist bronchodilator used to treat chronic obstructive pulmonary disease (COPD). If you struggle to afford your prescription medications, this program may help you receive the treatment you need. ## About Perforomist Perforomist is a prescription inhalation solution containing formoterol fumarate, a bronchodilator that helps open airways and improve breathing in patients with COPD. It is administered using a nebulizer and is typically prescribed for maintenance treatment to prevent symptoms and improve lung function. Your healthcare provider will determine if Perforomist is the right medication for your condition. ## Who Qualifies for This Program? To be eligible for the Viatris Patient Assistance Program, you must meet all of the following requirements: **Residency:** You must be a current United States resident, including U.S. territories. **Insurance Status:** You must be fully uninsured, or if you have insurance, you must have no prescription drug coverage. This means you cannot have coverage through private insurance plans, Medicaid, Medicare (including Parts A, B, Medicare Advantage, or Part D), TriCare, or other prescription drug plans. **Financial Need:** You must demonstrate financial need. The program does not publish specific income thresholds; instead, each applicant is individually assessed based on the financial information provided in the application. **Valid Prescription:** Your medication must be prescribed by a licensed U.S. healthcare professional for an FDA-approved indication. ## Income Eligibility The Viatris Patient Assistance Program uses a needs-based assessment rather than strict income cutoffs. This means your eligibility depends on your individual financial circumstances, including household income, expenses, and ability to pay for medications. During the application process, you will provide financial information that the program will review to determine if you qualify. While specific income thresholds are not publicly listed, the program generally considers patients with limited financial resources. If you are unsure whether you qualify, you are encouraged to apply—the program will assess your situation individually. ## Insurance Requirements You must be **fully uninsured** or have insurance **without prescription drug coverage** to qualify. This is a strict requirement: - If you have any prescription drug insurance (including Medicare Part D, Medicaid, private insurance, or employer-sponsored plans), you are not eligible for this program. - If you are uninsured but have medical insurance without prescription coverage, you may qualify. - The program will verify your insurance status as part of the application process. If you have insurance with prescription coverage, you may want to explore other assistance options or speak with your healthcare provider about alternative medications or programs. ## How to Apply: Step-by-Step **Step 1: Gather Required Documents** Before starting your application, collect the following: - Proof of income (recent pay stubs, tax returns, or benefit statements) - Proof of residency (utility bill, lease agreement, or government-issued ID) - Your prescription for Perforomist from your healthcare provider - Information about your current insurance status (or confirmation that you are uninsured) **Step 2: Complete the Application** Obtain the Viatris Patient Assistance Program application form. You can request this by calling the program at **(888) 417-5780** (Monday-Friday, 8 AM-5 PM EST). The application is available in interactive PDF format, allowing you to type your information directly into the form. Complete every section of the application thoroughly and accurately. Incomplete applications will delay processing or may result in denial. Required information includes: - Your full name, contact information, and date of birth - Your healthcare provider's name and contact information - Your prescription details - Your household income and financial information - Your insurance status - Your signature and date **Step 3: Submit Your Application** Once completed and signed, submit your application by: - **Fax:** (877) 427-7290 - **Email:** ViatrisPAP@viatris.com - **Phone:** Call (888) 417-5780 to discuss your application or ask questions **Step 4: Wait for Approval** The program will review your application and notify you of the decision. If additional information is needed, the program will contact you within 5 business days. Once all required information is received, you will be notified of the eligibility determination within 3 business days. ## Timeline and Medication Delivery After your application is approved, Perforomist will be shipped directly to you. The program does not specify exact delivery timeframes, so ask about expected delivery when your application is approved. **Program Duration:** Once approved, your eligibility lasts for 12 months. During this period, you can receive up to 11 refills of your medication for each unique enrollment. ## What If Your Application Is Denied? If your application is denied, you have several options: 1. **Ask Why:** Contact the program at (888) 417-5780 to understand the reason for denial. You may be able to provide additional information or clarification. 2. **Reapply:** If your circumstances change (such as your insurance status or income), you can submit a new application. 3. **Explore Alternatives:** Ask your healthcare provider about: - Other patient assistance programs - Generic alternatives to Perforomist - Pharmaceutical company discount programs - State or local assistance programs - Community health centers that offer reduced-cost medications 4. **Contact Patient Advocacy Organizations:** Organizations focused on COPD or respiratory health may have resources or information about additional assistance programs. ## Reauthorization and Refills Your assistance is valid for 12 months from the date of approval. Before your 12-month period ends, you will need to reauthorize your enrollment to continue receiving medication through the program. The program will contact you with instructions for reauthorization. During your 12-month enrollment period, you can receive up to 11 refills of your prescription. Work with your healthcare provider to ensure refills are requested in time. ## Important Reminders - **Complete Applications Only:** Incomplete applications will not be processed. Ensure all sections are filled out and signed. - **Verification:** The program will verify your insurance status and financial information. Provide accurate details. - **No Guarantee:** Applying to the program does not guarantee assistance will be approved. Each applicant is individually assessed. - **Privacy:** Your personal health information will be kept confidential and used only to determine eligibility and administer the program. ## Contact Information **Viatris Patient Assistance Program** - **Phone:** (888) 417-5780 (Monday-Friday, 8 AM-5 PM EST) - **Fax:** (877) 427-7290 - **Email:** ViatrisPAP@viatris.com Don't hesitate to call with questions about eligibility, the application process, or your status. ## Disclaimer This guide provides general information about the Viatris Patient Assistance Program based on publicly available program details. Program requirements, eligibility criteria, and procedures may change. For the most current and accurate information, contact the program directly at the phone number or email listed above. This guide is not a guarantee of program eligibility or assistance. Always consult with your healthcare provider about your treatment options and medication needs.

Program information last verified: March 30, 2026