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      Patient Assistance Program Center

Program Details

Patient Assistance Program

Spiriva HandiHaler (tiotropium bromide inhalation powder)
Address: PO Box 66745
St. Louis, MO 631666745
Phone: 1-800-556-8317 Provider Phone:
Fax: 1-866-851-2827 Website: Program Website
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
    Attachments Required: Financial
    Physician License #
    Both DEA and State
    Prescriber Signature
    Application may be
    Eligibility determination
    letter sent:
    Both Provider and Patient
    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.
  • Last Updated: 08/11/2017




    Application Forms
    & Instructions

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

    DocumentForm (English)

    Document HIV Common Application


    Print-friendly version

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