Program Contact Info / Application Submission
Program	Boniva Patient Assistance Program
Company	Roche
Address	P.O. Box 29064 Phoenix, AZ 85038
Phone	866-247-5084
Program Requirements
Details	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 incomeNOT 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 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 apply for a new application via mail
Refills	Refills accepted Patients can apply for refills Doctors can apply for refills Advocates can apply for refills Can apply for refills via phone
Re-Applications	Re-Applications accepted Patients can apply for Re-Applications Doctors can apply for Re-Applications Advocates can apply for Re-Applications Can Re-Apply via mail
Eligibility
Limitations	Patients may be eligible with existing prescription coverage on a case by case basis Patients are eligible if prescription is not covered Patients may be eligible if they are accepting Medicare part D on a case by case basis