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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: 11/20/2014

    		  

     

     


    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 Instructions (English)


    Document HIV Common Application

     

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