BI Cares Foundation Patient Assistance Program

Who is eligible?

All applications are reviewed in accordance with BI Cares Program eligibility criteria. To be eligible, you

must:

❑ Be a resident with a physical address within the United States or US Territory

❑ Have one of the insurance coverage circumstances outlined below:

o No health coverage

o Not enough coverage to obtain the medication

(eligible drugs are listed below)

❑ Not have access to alternate sources of coverage or funding for your medication

❑ Meet household income guidelines established by BI Cares

Wha

t information is needed to submit an application?

The following items should be submitted to the BI Cares Patient Assistance Program for the application to

be considered complete:

❑ Complete Sections 1-4 including signatures

❑ Have a Healthcare Provider complete Sections 5 & 6 including an original signature

❑ Proof of income may be required (See Section 2 for more information)

Wha

t medications are eligible?

he following medications are eligible for the BI Cares Patient Assistance Program:

o Aptivus

Capsules

o Atrovent

HFA

o Combivent

Respimat

o Glyxam

o Jar

diance

o J

entadueto

o J

entadueto

o Spiriva

HandiHaler

o Spiriva

Respimat

o St

iolto

Respimat

o S

triverdi

Respimat

o Syn

jardy

o Syn

jardy

o Tradjenta

o T

rijardy

The Boehringer Ingelheim Cares Foundation (BI Cares) Patient Assistance Program (the “Program”) is free of

charge to eligible US patients who apply to and are enrolled in the Program.

Please Note: The Boehringer Ingelheim Cares Foundation, Inc. is not affiliated with any third-party individual or

organization that may charge patients a fee(s) to assist them in applying to our Program or ordering refills through

our Program. These individuals or organizations are acting independently of the Boehringer Ingelheim Cares

Foundation and do not have our Foundation’s consent.

P.O. Box 5520, Louisville, KY 40255

Phone: 1-800-556-8317

Hours: M-F, 8:30a – 6:00p ET

Fax: 1-866-851-2827

BI Cares Foundation

Patient Assistance Program

Please print in blue or black ink.

BI Cares Foundation Patient Assistance Program Application

Patient Assistance

Program

Please Print Clearly

Application

BI Cares Patient Assistance Program Phone: 1-800-556-8317

P.O. Box 5520, Louisville, KY 40255 Fax: 1-866-851-2827

Application Page

1 of 4

Section 1: Patient Information

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Note: Delivery will be to patient’s address unless otherwise indicated by the patient. Aptivus

will be shipped to the

Healthcare Provider.

Preferred Daytime Phone Number *:

( ) –

* I understand this Program may include calls and emails from BI Cares Foundation and its third-party partners

(“Partners”). These periodic communications are intended to provide timely updates regarding the status of your

application and other information related to your participation in the Program. By answering “YES” below, you

indicate that you would like to receive support via texts as well.

Please Send me Text Notifications on Program & Shipment Statuses: Yes No

YES, I agree to receive periodic messages from BI Cares Foundation and its Partners about my participation in the

Program and other related information at the telephone number provided below. I understand texts may be sent via

an autodialer and are not a condition of enrollment in the Program. Standard message and data rates may apply.

Please provide the preferred phone

number for text notifications:

( ) –

/ /

Date of Birth (MM/DD/YYYY):

Gender (Please Check):

Male

Female

Last 4 Digits of SSN:

Note: This is Required for Income Verification

Preferred Language (Please Check): English Spanish Other:

Section 2: Patient Financial Information

How many people live in your household (including yourself)?

What is the total household income for a year?

Total patient household assets (Include 401(k), second home, IRA, etc. Do

not include primary home or car))

I understand that to qualify for free product my total income must meet the Program income guidelines and that my income will

be validated through a third-party income assessment tool based on the information I provide. If my income cannot be verified

through the third-party assessment, BI Cares will request documentation from me such as my IRS 1040 form or other proof of

income to verify my financial information. I agree to provide such information in a timely manner. BI Cares may request information

from me, my health care provider or my insurance company to verify my insurance information. I understand that any free

product provided to me through BI Cares is contingent upon my meeting eligibility criteria; and that BI Cares reserves the right to

make an independent determination of my financial and medical need.

Patient / Authorized Rep. Signature: Date:

Please print in blue or black ink.

BI Cares Foundation Patient Assistance Program Application

Patient Assistance

Program

Please Print Clearly

Application

BI Cares Patient Assistance Program Phone: 1-800-556-8317

P.O. Box 5520, Louisville, KY 40255 Fax: 1-866-851-2827

Application Page

2 of 4

Section 3: Insurance Information

check one

Have you received disability payments from Social Security for more than 24 months? Yes No

Have you received a denial letter from Medicare Low Income Subsidy? If yes, please attach a

recent copy of this letter along with your application.

Yes No

Do you have Medicare Part D or Medicare Advantage? Yes No

Do you have Medicaid? Yes No

Do you have prescription drug coverage from a commercial or private health insurer? (Not

including Medicare Part D prescription benefits)

Yes No

Do you receive Veterans Affairs prescription drug coverage benefits? Yes No

Section 4: Patient Attestation

By signing the below, you, the Patient, attest and certify that:

• The information provided in this application and any additional information provided as a part of the application

process is current, complete and accurate to the best of your knowledge.

• You cannot afford the medication requested and: (1) have no coverage; (2) have no coverage for the medication

for which you’ve applied for support under the Program; or (3) have coverage for the medication but have an out-

of-pocket expense you cannot afford.

• You will not seek reimbursement from any insurer or government program for any medication dispensed from

the Program and you will immediately notify the Program if the medication requested is/are no longer medically

necessary or if your insurance/financial status has changed.

In addition, by signing the below, you, the Patient, understand and agree that:

• Any medication supplied as a result of this Application is for your use only, and shall not be sold, traded, bartered,

transferred or returned for credit. No claims involving this medication shall be submitted to any third party (such

as Medicare, Medicaid, Veterans Affairs or any other public programs) for reimbursement.

• Completing this Application does not guarantee that assistance will be provided to you.

• The information provided in this Application is subject to random audits and verification. During such audits and

verification processes, you may be asked for additional supporting documentation.

• BI Cares may change this Program at any time and reserves the right to terminate your enrollment at any time

due to lack of eligibility or related factors.

• The medication made available to you under this Program may be denied if you do not fully cooperate with efforts

made to verify the information provided in this application, or if you do not take steps to secure other forms of

payment for your medication after being notified of other programs for which you may be eligible.

BI Cares is not obligated to verify any of the information contained in this Application or to confirm other medications

that you are taking.

By signing below, I give my permission to share my personal information with Boehringer Ingelheim Cares Foundation,

Inc., its representatives, agents, and other third-party partners supporting the administration of the Program, who

may contact me with follow-up inquiries and who may report my personal information to health authorities to comply

with applicable rules and regulations.

Please print in blue or black ink.

BI Cares Foundation Patient Assistance Program Application

Patient Assistance

Program

Please Print Clearly

Application

BI Cares Patient Assistance Program Phone: 1-800-556-8317

P.O. Box 5520, Louisville, KY 40255 Fax: 1-866-851-2827

Application Page

3 of 4

First Name:

Last Name:

By signing the below, I give my permission to my healthcare practitioners, pharmacy providers, health plan, and

insurers to share my personal and health information with BI Cares, its representatives, agents, and other third-party

partners supporting the administration of the Program (collectively, “BI Cares and its Partners”). I understand my

personal and health information may include, but not be limited to, my medical condition, treatment, care management,

health insurance, medication history, and prescriptions (the “Information”).

I give BI Cares and its Partners authorization to use and further disclose the Information for the following purposes:

• To process my application for the Program, validate the information provided in this application, and verify my

eligibility for participation in the Program, investigate and verify my insurance benefits and/or identify other patient

assistance resources.

• To notify me if I do not meet the eligibility requirements or if there are any changes to the Program.

• If eligibility is confirmed, to facilitate my participation in the Program, which will include the dispensing and delivery

of medication.

• To assist in the general administration of the Program and conduct any additional services described above and

related to the Program.

• To comply with applicable rules and regulatory requirements related to safety information received in the course

of administering the Program, where such information is collected in the interest of patient safety. Such

information will be filed in a global database and the information may be reported to regulatory authorities.

Boehringer Ingelheim will retain the data as long as required by applicable rules and regulations.

Without limiting the purposes for the use and disclosure of the Information set forth above, I understand:

• BI Cares and its Partners respects your privacy and implements safeguards in an effort to keep the Information

confidential, but the Information released under this authorization may no longer be protected by state and federal

privacy laws and that the Information may be lawfully re-disclosed by recipients.

• That I may cancel this authorization at any time by giving written notice to BI Cares at the address noted on this

application, but my cancellation will only apply to future use of the Information and not change any actions taken

before my canceling.

• That I have a right to receive a copy of this authorization from my healthcare practitioner and/or BI Cares, and that

I may inspect/obtain a copy of the Information disclosed pursuant to this authorization.

• That I can refuse to sign this authorization and it will not impact the way my healthcare practitioners, pharmacy

providers, health plan, and insurers treat me, but if I do not sign this authorization, I will not be able to participate

in the Program.

• This authorization is valid from the date of execution and will expire at the end of my enrollment in the Program

or the date I am notified I am ineligible for the Program, unless I revoke my consent per the terms of this

authorization.

Patient / Authorized Rep. Signature: Date:

Patient Authorization to Share Health Information

Please print in blue or black ink.

BI Cares Foundation Patient Assistance Program Application

Prescriber Signature:

(Original – Stamps NOT ACCEPTED)

Date:

Application Page 4 of 4

Section 5: Prescriber Information

Prescriber Name:

NPI:

Specialty:

SLN #:

SLN Exp. Date:

Site/ Facility Name:

Office Contact Name:

Address

City:

State:

Zip Code:

Office Phone:

Office Fax:

Section 6: Prescription & Medication Information*

First Name:

/ /

Product Name/ Strength:

90 days

Directions:

1 2 3

Medication Allergies?

Yes

Last Name: Date of Birth:

Days Supply:

Refills(check one):

If Yes, please list all drug allergies:

Current Medications (please list):

* A separate prescription form may be attached to this application and a separate form should be attached if required by federal

and state law.

The information you, the Prescriber, provides as part of this BI Cares Patient Assistance Program application (“Application”) will

be used by Boehringer Ingelheim Cares Foundation, Inc. (“BI Cares”) and its affiliates, agents, representatives and service

providers to (1) process this Application and verify the information contained in this Application, (2) administer, analyze, and

improve the BI Cares Patient Assistance Program (“Program”), (3) improve and tailor our products and services to better serve

you, (4) communicate with you about your experience with the Program, and/or (5) send you materials and other helpful

information and updates relating to BI Cares programs (“Services”).

By signing below, you, the Prescriber, attest and certify that:

 The information provided in this Application and any additional information provided as part of the Application process is

current, complete, and accurate to the best of your knowledge.

 To the best of your knowledge, the patient identified in this Application cannot afford the medication requested and (1) has

no coverage or (2) has no coverage for the medication or (3) has coverage for the medication but has an out-of-pocket

expense he/she cannot afford.

 You will not seek reimbursement for any medication dispensed from the Program.

 You will notify the Program immediately if the medication requested is no longer medically necessary for this patient’s

treatment or if you become aware that your patient’s insurance or financial status has changed.

 You have a signed copy on file of your patient’s current and completed HIPAA Authorization, or any other authorization or

consent required by law, so that you may share patient health information with the Program, including BI Cares and its

affiliates, agents, representatives and service providers.

In addition, by signing below, you, the Prescriber, understand and agree that:

 Any medication supplied as a result of this Application is for the use of the patient named on this form only, and shall not

be sold, traded, bartered, transferred or returned for credit. No claims involving this medication shall be submitted to any

third party (such as Medicare, Medicaid, Veterans Affairs or any other public programs) for reimbursement.

 Completing this Application does not guarantee that assistance will be provided to your patient.

 The information provided in this Application is subject to random audits and verification.

 BI Cares may change this Program at any time and reserves the right to terminate your patient’s enrollment at any time

due to lack of eligibility or related factors.

Fax the Complete Application:1-866-851-2827

Phone: 1-800-556-8317