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Program Details

BOEHRINGER INGELHEIM CARES FOUNDATION, INC.
Patient Assistance Program

Spiriva HandiHaler (tiotropium bromide inhalation powder)
 
CONTACT INFO
Address: PO Box 66745
St. Louis, MO 631666745
Phone: 1-800-556-8317 Provider Phone:
Fax: 1-866-851-2827 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patients must be a legal U.S. resident ineligible for prescription drug assistance through Medicaid, Medicare, Medicare Part D or private insurance.
  • Patients must meet the established financial criteria. Some Medicare eligible patients who have difficulty meeting their Part D drug costs and who do not quality for other assistance may be eligible as long there is no other prescription drug coverage and meet the rest of the eligibility criteria.
  • Applications are evaluated on a case by case basis.
  • Income at or below: Not Published
    Medical expenses can be deducted from reported income: No
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Prescription
    Physician License #
    Required:
    Both DEA and State
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    No
    Eligibility determination
    letter sent:
    Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Either Provider and Patient
    Aptivus and Viramune XR can only be shipped to the prescriber office.
    Quantity in Shipment: 90 days
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Refill Policy: 3 refills
    Other Information:
  • All products are registered trademarks of Boehringer Ingelheim. Program is subject to change without notice.
  • Physicians can also submit applications online by visiting http://www.rxhope.com.
  • Last Updated: 09/18/2013

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)


    Document Form (Spanish)


    Document HIV Common Application



     

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