| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 2. Scroll down to see them all. |
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BI Cares Patient Assistance Program: GilotrifThis program provides medication at no cost. |
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Provided by: Boehringer Ingelheim Cares Foundation, Inc. |
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BI Cares Patient Assistance Program - Gilotrif TEL: 855-297-5904FAX: 855-297-5905 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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BI Cares Patient Assistance Program - Gilotrif Application |
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BI Cares Patient Assistance Program - Gilotrif Eligibility Information |
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Medications |
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Eligibility Requirements |
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| 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 residing in the US or US territory | ||
Application |
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| Obtaining | Call or download | ||
| Receiving | Faxed, mailed or downloaded from website | ||
| Returning | Fax from Doctor's office | ||
| Doctor's Action | Complete section, sign, attach required documents | ||
| Applicant's Action | Complete section, sign, attach required documents | ||
| Decision Communicated | Patient notified in writing | ||
| Decision Timeframe | Not specified | ||
Medication |
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| Amount/Supply | Up to 60 day supply | ||
| Sent To | Patient's home, unless otherwise noted | ||
| Delivery Time | Not specified | ||
| Refill Process | Contact program for details. | ||
| Limit | Not specified | ||
| Re-application | New application yearly | ||
Additional Information |
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| Updated May 08, 2023 | |||
| 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 |
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Provided by: Patient Access Network Foundation |
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TEL: 866-316-7263FAX: 866-316-7261 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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Patient Access Network Foundation (PAN) Application: Contact program |
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Medications |
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Eligibility Requirements |
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| 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 |
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| Obtaining | Call or complete online | ||
| Receiving | Complete online or by phone | ||
| Returning | Not applicable | ||
| Doctor's Action | Varies | ||
| Applicant's Action | Call for information or inform doctor that he/she is in need | ||
| Decision Communicated | Patient and Doctor are notified | ||
| Decision Timeframe | Within 48 hours | ||
Medication |
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| Amount/Supply | Not applicable | ||
| Sent To | Patient is sent savings 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 |
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| *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. |
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| Updated May 01, 2023 | |||
