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| 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 required Drivers license NOT required Proof of Income NOT required Copy of most recent tax return such as 1040, 1099 required as proof of income Letter from Doctor stating zero incomeNOT required as proof of income Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements required as proof of income Most recent check/check stub copy required as proof of income Letter from employer required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement required as proof of income Award Letter for Alimony/Child Support, Unemployment required as proof of income Notarized statement from patient stating zero income required as proof of income | |||||||||||||||||||||||
| Delivery of Medication | ||||||||||||||||||||||||
| Delivery Options | Can be delivered directly to the patient Can NOT be delivered directly to the doctor Shipped as a voucher card | |||||||||||||||||||||||
| 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 NOT accepted Patients can NOT apply directly to the program Doctors can NOT apply directly to the program Advocates can NOT apply directly to the program Can apply for a new application via phone Can NOT apply for a new application via fax Can NOT apply for a new application via mail | |||||||||||||||||||||||
| Refills | Refills NOT accepted Patients can apply for refills Doctors can NOT apply for refills Advocates can NOT apply for refills Can NOT apply for refills via phone Can NOT apply for refills via fax Can NOT apply for refills via mail | |||||||||||||||||||||||
| Re-Applications | Re-Applications NOT accepted Patients can apply for Re-Applications Doctors can NOT apply for Re-Applications Advocates can NOT apply for Re-Applications Can Re-Apply via phone Can NOT Re-Apply via fax Can NOT Re-Apply via mail | |||||||||||||||||||||||
| Appeals | Income Appeals NOT accepted Patients can apply for Income Appeals Doctors can NOT apply for Income Appeals Advocates can NOT apply for Income Appeals Hardship Appeals NOT accepted Patients can apply for Hardship Appeals Doctors can NOT apply for Hardship Appeals Advocates can NOT apply for Hardship Appeals Can apply for an appeal via phone Can NOT apply for an appeal via fax Can NOT 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 NOT eligible if LIS is denied Patients are eligible with existing prescription coverage Patients are NOT eligible if prescription is not covered Patients are eligible if prescription coverage has been exhausted Patients may be eligible if they are accepting Medicare on a case by case basis Patients are 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 eligible if Medicare coverage has been exhausted | |||||||||||||||||||||||
| Appeals | ||||||||||||||||||||||||
| Conditions | Appeals will NOT consider out-of-pocket expenses Appeals will NOT consider total medical expenses Appeals may be made before the patient has been denied | |||||||||||||||||||||||
| Other Medications | ||||||||||||||||||||||||
| Other Medications available in this program |
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