Momentum Savings Card for Myrbetriq^® (mirabegron extended-release tablets)

The Momentum Savings Card (Savings Card) for Myrbetriq is intended to help eligible patients offset the cost of their prescription copay. Eligible patients may save up to $70 every month for a full year and, for some patients it may cover the entire copay of their first prescription.^a The patient is responsible for the first $20 plus any differential over $90 for each individual prescription.

The Savings Card is available to those 18 years of age and older. The Savings Card is not available for patients whose prescription claims are reimbursed, in whole or in part, by any state or federal government program, including but not limited to Medicaid, Medicare, Medigap, Veterans Affairs (VA), Department of Defense (DoD), TRICARE, Puerto Rico Government Health Insurance, or any other state patient or pharmaceutical assistance program. This offer is void where prohibited by law. Astellas reserves the right to rescind, revoke, or amend this offer without notice. This program is not insurance.

Obtaining the Savings Card

• From their healthcare provider
• By requesting the card here
• By calling 1-855-326-1404 and having the Savings Card mailed to them
  (in approximately 4–6 days)

Activating the Savings Card

Savings Cards must be activated online here or by calling 1-855-326-1407 (or 1-855-326-1408). Once the Savings Card is activated, it can be printed for immediate use. Patients should take their prescription, along with their Savings Card, to a participating retail pharmacy.^b

^a Eligibility and enrollment criteria apply.

^b If patients use a mail-order pharmacy, they should contact their pharmacy provider to ensure that this offer will be accepted. If the mail-order pharmacy will not process the Savings Card, they should call 1-855-326-1404 (Monday–Friday, 8:00 am–8:00 pm ET, excluding holidays) and request to speak to an agent. An agent will mail a Direct Member Reimbursement (DMR) form to them. The form should be completed and returned to the address on the form, along with their pharmacy receipt. If patients are eligible, they will receive their benefit in the mail. They can also visit www.patientrebateonline.com to obtain a DMR form.