Mail to: Boehringer Ingelheim CARES Foundation, Inc.
PO Box 66745
St. Louis, MO 63166-6745
Hours of Operation: Monday – Friday 7:30 am – 5:30 pm CST
Patient Assistance Program for Medicare Beneficiaries
Patients wishing to be considered for eligibility must submit a completed application along with proof of
income and prescription drug expenses (see below).
Section 1 – Physician and Prescription Information
All physician information must be completed. Prescription information may be entered or attached.
Physician signature is required.
Section 2 – Patient Information
This section must have all patient information completed.
Section 3 – Financial Information
Patients must list all sources of income and attach proof of income. Please attach a copy of the patient’s
most recent federal income tax return. The program accepts copies of IRS Forms 1040, 1040A,
1040EZ, 1040X, 1040NR-EZ, IRS Telefile, 8453, 8879, 1722 (transcript), Federal Tax Transcript,
Federal Recap Form
If the patient has not filed a federal income tax return in the previous sixteen (16) months, please submit
a copy of each of the following that apply:
• IRS Form 4506T
• Railroad Retirement Statements
• W-2 Tax Statement
• Statements of Interest, Dividends or
• Pension Statements
other Income (1099-INT, 1099, 1099T,
• Disability Statements
• Social Security Checks/Statements
Section 4 Social Security Low Income Subsidy
Patients must complete this section.
**If the patient has applied for the Medicare Part D Low Income Subsidy (also known as “Extra
Help”) through the Social Security Administration within the past year and has been denied,
please attach a copy of the denial letter.
Section 5 – Prescription Drug Information
Patients must complete all four insurance boxes and enter the total amount that they have spent (out-of-
pocket) for prescriptions in the current calendar year (i.e., since January 1). The program requires
that a patient must have spent at
least 3% of their annual household income on prescriptions during the
Only prescription costs in the current calendar year will be considered.
current calendar year.
Please attach a copy of the most current Explanation of Benefits from the Medicare prescription
drug plan or a print-out from the pharmacy.
Section 6 – Patient Attestation and Signature (required)
Patient signature is required for eligibility determination.