Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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BI Cares Patient Assistance Program - Gilotrif

This program provides medication at no cost.

Provided by: Boehringer Ingelheim Cares Foundation, Inc.

BI Cares Patient Assistance Program - Gilotrif
PO Box 5697
Louisville, KY 40255

TEL: 855-297-5904


FAX: 855-297-5905
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

BI Cares Patient Assistance Program Gilotrif Application

 

Medications

  • afatinib tablet (Gilotrif) Tablet
 

Eligibility Requirements   

Insurance Status Must be uninsured or underinsured
Those with Part D Eligible? Yes, but contact program for details
Income Based on FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Must be a US resident
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail from Doctor's office
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach proof of income and other requested documentation
Decision Communicated Patient notified in writing
Decision Timeframe Not specified
   

Medication

Amount/Supply Up to 30 day supply
Sent To Patient's home, unless otherwise noted
Delivery Time Not specified
Refill Process Patient or Doctor's office needs to contact company
Limit Not specified
Re-application New application yearly
   

Additional Information


Updated September 21, 2020


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2.
 

Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation


TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Patient Access Network Foundation (PAN) Application: Contact program

 

Medications

  • afatinib tablet (Gilotrif) Tablet
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria FDA Approved Diagnosis - See Program Website for Details
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.

Updated September 28, 2020