RxAssist Home
RxAssist Home Home  |  About Us  |  Contact RxAssist          
      Patient Assistance Program Center
 
 

Program Details

BOEHRINGER INGELHEIM CARES FOUNDATION, INC.
BI Cares Patient Assistance Program

Combivent Inhalation Aerosol (ipratropium bromide; albuterol sulfate)
 
CONTACT INFO
Address: PO Box 5520
Louisville, KY 40255
Phone: 1-800-556-8317 Provider Phone:
Fax: 1-866-851-2827 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must be uninsured or underinsured.
  • Patients with Medicare Part D may be eligible, contact program for details.
  • Patients must meet the established financial criteria which is different for groups of medication. See and print Eligibility Information sheet.
  • 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:
    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: Not Published
    Other Information:
  • All products are registered trademarks of Boehringer Ingelheim. Program is subject to change without notice.
  • Last Updated: 12/06/2023

     

     

     


    Application Forms
    & Instructions

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


    Document PAP Application


    Document Eligibility Information


    Document HIV Common Application



     

    Print-friendly version

    This information is for informational purposes only and is not meant to be a substitute for professional medical advice, diagnosis or treatment. Neither RxAssist nor RxVantage is offering advice, recommending or endorsing any specific prescription drug, pharmacy or other information on the site. Neither RxVantage nor RxAssist provide any warranty for any of the pricing data or other information. Please seek medical advice before starting, changing or terminating any medical treatment. Third party logos, trademarks, brand names and images contained on rxassist.org or rxvantage.com are for demonstration purposes only and are owned by their respective rights holders, who are not affiliated with this Site.

    Copyright © 2024, RxVantage, all rights reserved.