Drug:

 
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, Opt 6
Fax 866-851-2827
Website http://us.boehringer-ingelheim.com/about/philanthropy/Patient_Assistance_Program.html
 
Program Requirements
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
Ship Time 10 - 14 business days
Delivery Options Can NOT be delivered directly to the patient
Can be delivered directly to the doctor

 
Application Process
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
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
Aggrenox 200-25mg - Stroke (Generic: dipyridamole + aspirin)
Atrovent Inhalation Aerosol 17g - Bronchodilator Pulmo (Generic: ipratropium bromide)
Combivent Inhalation Aerosol 14g - COPD Pulmo (Generic: ipratropium bromide + albuterol sulfate)
Micardis 20mg - angiotensin II receptor antagonists Blood Pressure (Generic: telmisartan)
Micardis HCTZ 40-12.5mg - angiotensin II receptor antagonists Blood Pressure (Generic: telmisartan + HCTZ)
Mirapex 0.125mg - dopamine agonist Parkinson's (Generic: pramipexole dihydrochloride tablets)
Spiriva HandiHaler 18mcg - Bronchodilator Pulmo (Generic: tiotropium bromide inhalation powder)
Mirapex 0.25mg - (Generic: pramipexole dihydrochloride tablets)
Mirapex 1.5mg - (Generic: pramipexole dihydrochloride tablets)
Mirapex 1mg - (Generic: pramipexole dihydrochloride tablets)
Mirapex 0.5mg - (Generic: pramipexole dihydrochloride tablets)
Micardis 40mg - (Generic: telmisartan)
Micardis 80mg - (Generic: telmisartan)
Micardis HCTZ 80-12.5mg - (Generic: telmisartan + HCTZ)
Micardis HCTZ 80-25mg - (Generic: telmisartan + HCTZ)
Mirapex ER 0.375 mg - (Generic: pramipexole dihydrochloride tablets)
Mirapex ER 0.75 mg - (Generic: pramipexole dihydrochloride tablets)
Mirapex ER 1.5 mg - (Generic: pramipexole dihydrochloride tablets)
Mirapex ER 3.0 mg - (Generic: pramipexole dihydrochloride tablets)
Mirapex ER 4.5 mg - (Generic: pramipexole dihydrochloride tablets)
Twynsta 40/5mg - (Generic: telmisartan)
Twynsta 40/10mg - (Generic: telmisartan)
Twynsta 80/5mg - (Generic: telmisartan)
Twynsta 80/10mg - (Generic: telmisartan)
Tradjenta tablet 5mg - (Generic: )