SAVE ON DALIRESP®(roflumilast) tablets

The DALIRESP $25 Savings Program*

Eligible, commercially insured patients pay $25 for each 30-day supply for up to 12 refills.

*Subject to eligibility; restrictions apply.

DALIRESP Savings Program
DALIRESP Savings Card

Download DALIRESP Savings Card

*Subject to eligibility; restrictions apply.

Download DALIRESP Savings Card

*Subject to eligibility; restrictions apply.

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.

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, and to patients 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 may pay as little as $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. 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 12/31/25. If you have any questions regarding this offer, please call 1-866-459-2015.

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.

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

Pharmacist Instructions for a Patient With an Eligible Third-Party Payer:

Submit the claim to the primary Third-Party Payer first, then submit the balance due to CHANGE HEALTHCARE as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code (eg, 8). The patient is responsible for the first $25 per 30-day supply. Reimbursement will be received from CHANGE HEALTHCARE.

Program managed by ConnectiveRx, on behalf of AstraZeneca.

 

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IMPORTANT SAFETY INFORMATION

What is the most important information I should know about DALIRESP?

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.

DALIRESP 250 mcg is a starting dose for the first 4 weeks only and is not the effective dose.

Please see full Prescribing Information, including Medication Guide.

You may report side effects related to AstraZeneca productsaccessobility-icon.