rxhelp360.org
| Drug Information | |
| Drug | Aggrenox 200-25mg |
| Generic Equivalent | dipyridamole + aspirin |
| Topic | Stroke |
| Program Contact Info / Application Submission | |
| Program | Boehringer Ingelheim Cares Foundation Inc. |
| Company | Boehringer |
| Form | Download PDF |
| Address | c/o Express Scripts Specialty Distribution Services, PO Box 66555, St. Louis, MO 63166-6555 |
| Phone | 800-556-8317 |
| Fax | 866-851-2827 |
| Website | http://us.boehringer-ingelheim.com/about/philanthropy/Patient_Assistance_Program.html |
| Program Details | |
| Details | Up to a 90-day supply is shipped to the doctor�s office. A new application with documentation is needed once a year. |
| Program Requirements | |
| Information | There is a seperate form to fill out for reorders which can be faxed or mailed as the original. |
| Details | Insurance card NOT required Drivers license required Proof of Income required Copy of most recent tax return such as 1040, 1099 NOT required as proof of income Letter from Doctor stating zero income required as proof of income Form 4506T (If taxes were not filed) required as proof of income Most recent bank statements NOT required as proof of income Most recent check/check stub copy NOT required as proof of income Letter from employer NOT required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement NOT required as proof of income Award Letter for Alimony/Child Support, Unemployment NOT required as proof of income Notarized statement from patient stating zero income NOT required as proof of income |
| Delivery of Medication | |
| Delivery Options | Can NOT be delivered directly to the patient Can be delivered directly to the doctor |
| Application Process | |
| App Process | Applications must be faxed or mailed from a doctors office. If mailed, all signatures should be original. |
| New Applications | New applications accepted Patients can apply directly to the program Doctors can apply directly to the program Advocates can apply directly to the program Can NOT apply for a new application via phone Can apply for a new application via fax Can apply for a new application via mail |
| Refills | Refills accepted Patients can NOT apply for refills Doctors can apply for refills Advocates can apply for refills Can apply for refills via phone Can apply for refills via fax Can apply for refills via mail |
| Re-Applications | Re-Applications accepted Patients can NOT apply for Re-Applications Doctors can apply for Re-Applications Advocates can apply for Re-Applications Can NOT Re-Apply via phone Can Re-Apply via fax Can Re-Apply via mail |
| Appeals | Income Appeals accepted Patients can NOT apply for Income Appeals Doctors can apply for Income Appeals Advocates can apply for Income Appeals Hardship Appeals accepted Patients can NOT apply for Hardship Appeals Doctors can apply for Hardship Appeals Advocates can apply for Hardship Appeals Can NOT apply for an appeal via phone Can apply via fax Can apply for an appeal via mail |
| Eligibility | |
| Eligibility | Patients must not have prescription coverage and must be ineligible for state and federal programs. Medicare patients are inelligible. The income guidelines are based on 200% of the federal poverty guideline. |
| Limitations | Patients are eligible if LIS is denied Patients are NOT eligible with existing prescription coverage Patients are eligible if prescription is not covered Patients are NOT eligible if prescription coverage has been exhausted Patients may be eligible if they are accepting Medicare on a case by case basis Patients are NOT eligible if they are accepting Medicare part D Patients may be eligible if the medication is not covered under Medicare on a case by case basis Patients are NOT eligible if Medicare coverage has been exhausted |
| Appeals | |
| Conditions | Appeals will consider out-of-pocket expenses Appeals will consider total medical expenses Appeals must be made after the patient has been denied |
| Other Medications | |
| Other Medications available in this program | |
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