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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 |
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| ELIGIBILITY
|
|
| Eligibility
Info: |
For Gilotrif, please contact the BI Cares Foundation Gilotrif Patient Assistance Program at 877-814-3915.
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 |
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|
APPLICATION |
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| 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
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| Other Information: |
All products are registered trademarks of Boehringer Ingelheim. Program is subject to change without notice. |
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Last Updated: 08/11/2017
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Application Forms
& Instructions
The following documents
are provided in interactive PDF format, allowing you to type information
directly into the form.
 Form (English)
HIV Common Application
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