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Application Summary

Program Name
Boehringer Ingelheim CARES Foundation Patient Assistance Program for Medicare Beneficiaries Medicare Brochure

Medication
Spiriva HandiHaler

Application Type
Form Available

Status
Blank Application Included

Overview Available

Contact Information Included

Medicare Prescription Drug Coverage, Low Income Subsidy

Form Available

Blank Application Included

Patient Safety

Mail to: Boehringer Ingelheim CARES Foundation, Inc. PO Box 66745 St. Louis, MO 63166-6745 Telephone 1-800-556-8317 Hours of Operation: Monday Friday 7:30 am 5:30 pm CST Fax: 1-866-727-5891

Patient Assistance Program for Medicare Beneficiaries Application Instructions 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 patients 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 W-2 Tax Statement Pension Statements Disability Statements Social Security Checks/Statements Railroad Retirement Statements Statements of Interest, Dividends or other Income (1099-INT, 1099, 1099T, 1099DIV)

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-ofpocket) 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 current calendar year. Only prescription costs in the current calendar year will be considered. 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.

Mail to: Boehringer Ingelheim CARES Foundation, Inc. PO Box 66745 St. Louis, MO 63166-6745 Telephone 1-800-556-8317 Hours of Operation: Monday Friday 7:30 am 5:30 pm CST Fax: 1-866-727-5891

Patient Assistance Program for Medicare Beneficiaries


Section 1 - Physician and Prescription Information
Physician Name Address: Prescription DEA or State License #: City: Phone: Fax: State: ( ( ) ) Zip:

Product Name/Strength Product Name/Strength

Quantity Quantity

Physician/Prescriber Attestation: To the best of my knowledge, this patient has no medical insurance other than Medicare Part D for this prescription. Patients on Medicaid and other public assistance programs are ineligible. I verify that the information provided is complete and accurate to the best of my knowledge. I understand that the medication prescribed above shall be sent to my office for dispensing to this patient, and I certify that the medication requested above shall only be used to treat this patient and I shall not seek reimbursement for this medication from any third party, including Medicare Part D.

Physician Signature:

Date:
SS#:

Section 2 - Patient Information


Patient Name: Street Address: City State U.S. Resident? Yes No

Date of Birth:

Male Female Phone ( ) Are you Disabled? Yes No

/
Zip Number of Household members (including self)? (circle one) 1 2 3 4 5 6 7 greater than 7

Are you a Veteran of the US Armed Forces? Yes No

Section 3 - Financial Information


Note: You must attach copy of your most recent federal Income Tax Return, i.e.,IRS Form 1040, 1040A, 1040EZ, 1099
List All Sources, Gross Monthly Amounts Salary/Wages Disability $_______________ $_______________ Social Security $_______________ Pension/ Retirement $_______________ Child Support/Alimony $_______________ Unemployment/ Work Comp $_______________

Total Gross Household Monthly Income: $_______________


Section 4 Social Security Low Income Subsidy (LIS) Note: A LIS Denial letter must be attached. 1. Are you eligible for Low Income Subsidy for Medicare Part D? Yes No Unsure Application Pending
Have you received a denial letter from the Low Income Subsidy? Yes No If yes, please attach a copy with your application. 3. If you received a denial from Low Income Subsidy by phone or do not have a copy of your denial letter, please initial the following statement: I confirm that I have received a denial (verbal or written) from the Medicare Part D Low Income Subsidy. _____initial here. 2.

Section 5 Prescription Drug Information Private Drug Coverage Medicaid Yes No Yes No

Medicare Yes No

Medicare Part D Yes No

Total Amount Spent on Prescription Medications Since January 1 (required): $____________


Note: In order to be eligible, a patient must have spent at least 3% of their annual household income on prescriptions during the current
calendar year. You must 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)


I certify that this information is complete and accurate to the best of my knowledge, and that I am unable to afford the medication requested. I understand that additional information may be requested to process this application, but that all medical and financial information will be kept confidential as required by law. I understand that the Product(s) made available to me under this program may be denied to me if I do not fully cooperate with efforts made to verify the information provided in this application, or if I do not take steps to secure alternative means of prescription coverage that are available to me, after I become aware of such alternatives. I certify that I shall not seek reimbursement for any medication dispensed as part of this program. I hereby authorize the Boehringer Ingelheim CARES Foundation, Inc. to obtain and disclose information from physicians, insurance companies and other information as necessary to verify the information provided in this application although Boehringer Ingelheim Cares Foundation, Inc. is not obligated to verify any of the information contained in Section 1 above or confirm other medications that I am taking.

Patients Signature:

Date:
PPARX APP 12/05/07

Medicare Brochure

You may also be eligible for the assistance program(s) that follow. For enrollment information, please contact the programs using the information listed below. Program Name
Medicare Brochure

Contact Information
Centers for Medicare & Medicaid Services 7500 Security Boulevard

Baltimore (800) 633-4227

MD

21244-1850

Product(s) covered by program:

Resources:
http://www.medicare.gov/

Eligibility:
Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. You might also qualify for coverage if you are a younger person with a disability or with End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant). Here are some simple guidelines. You can get Part A at age 65 without having to pay premiums if:<ul><li>You are already receiving retirement benefits from Social Security or the Railroad Retirement Board.</li><li>You are eligible to receive Social Security or Railroad benefits but have not yet filed for them.</li><li>You or your spouse had Medicare-covered government employment.</li></ul>If you are under 65, you can get Part A without having to pay premiums if:<ul><li>You have received Social Security or Railroad Retirement Board disability benefit for 24 months.</li><li>You are a kidney dialysis or kidney transplant patient.</li></ul>While you do not have to pay a premium for Part A if you meet one of those conditions, you must pay for Part B if you want it. The Part B monthly premium in 2005 is $78.20. It is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not get any of the above payments, Medicare sends you a bill for your Part B premium every 3 months.

Medicare Low Income Subsidy Worksheet


What You Need to Complete the Application for Help with Medicare Prescription Drug Plan Costs
Social Security and the Centers for Medicare & Medicaid Services are working together to get you extra help with your prescription drug costs. To determine if you could be eligible for this extra help, Social Security will need to know your income and the value your savings, investments and real estate (other than your home). You may qualify for extra help if you have: Limited income (below $16,245 for an individual or $21,855 for a married couple living together). Even if your annual income is higher, you still may be able to get some extra help with your monthly premiums, annual deductibles and prescription co-payments related to a Medicare prescription drug plan. Some examples where your income may be higher include if you or your spouse: o Support other family members who live with you; o Have earnings from work; or o Live in Alaska or Hawaii; and Limited resources (below $12,500 for an individual or $25,010 for a married couple living together). These resource limits can be slightly higher (an additional $1,500 per person) if you will use some of your money for burial expenses. Identify the things you own by yourself, with your spouse or with someone else, but do not include your home, vehicles, life insurance policies, burial plots or personal possessions. Review all your income. Gather your records in advance to save time. Remember that this worksheet is not an application. This worksheet can assist you in completing the actual application for extra help. Statements that show your account balances at banks, credit unions or other financial institutions; Investment statements; Stock certificates; Tax returns; Pension award letters; and Payroll slips. Social Security needs to know information about your (and your spouses if you are married and living together) income and resources. You may choose to have someone help you when you do business with Social Security.

PPA-SSLTRFORM

Medicare Low Income Subsidy Worksheet

Resources
Bank accounts, including: checking, savings and certificates of deposit Stocks, bonds, savings bonds, mutual funds, individual retirement accounts (IRAs) or other investments Cash at home or anywhere else Any real estate other than your home

Value

Income
Railroad retirement

Monthly Amount
$_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________

$_____________

Veterans benefits Other pensions or annuities

$_____________ $_____________ $_____________

Alimony Net rental income Wages Self-employment net earnings Workers compensation Other income

NOTE: Social Security will use the monthly amount of your benefits from our records. You do not have to tell us this information.

Once you have completed the information above, please contact Social Security to apply online at www.socialsecurity.gov/extrahelp -- or call 1-800-772-1213 to apply over the phone or to request the Application for Extra Help with Medicare Prescription Drug Plan Costs (SSA-1020). To get help from a non-profit organization with completing your application, or to get answers to any questions regarding this benefit, please contact the number provided on the cover letter included in this mailing. To learn more about the Medicare prescription drug plan, call 1-800-MEDICARE (1-800-6334227) or visit www.medicare.gov.

PPA-SSLTRFORM

PhRMAs Commitment to Patient Safety:


Good communications are the key to safe and effective use of medications. There is information you should be sure to provide to your doctor, and information you should be sure to find out about your medicine. Tell each doctor you consult about: All your symptoms and answer all questions as accurately as you can. This will help the doctor determine your proper treatment. All the medicine you take, including non-prescription products such as aspirin or laxatives. Keep a list of your medicines, if necessary, or take the containers with you to show the doctor. This is especially important on your first visit to a doctor or if, when traveling, you need to consult someone who is not your regular doctor.

Any bad reaction you have had to a medicine. Adverse reactions, or side effects, may appear as blurred vision, dizziness, nausea, skin rash, or other unusual feelings you did not experience before you took the medicine. If you routinely drink even small amounts of alcohol each daysuch as wine with meals. Your doctor may advise against this while you are taking prescription medication.

My Health Information
Using This Form

Fill out all of the information that you know. Call a loved one or your health care provider if you need help or have questions concerning your medical information. Make three copies of both sides of the completed record. Keep one copy in your wallet or purse, provide one to a family member or friend, and share the other with your health care providers and pharmacists at all visits. You should update this record when: Your contact information, insurance provider, health care provider or pharmacy changes. Your medical condition changes. You start or stop taking a medicine. Your health care provider changes the dose of your medicine. You visit the health care provider or pharmacist.

Personal Information Name Date of Birth Phone Number Address Emergency Contact Name Relationship Phone Number Insurance Provider (if applicable) Name Type (e.g., PPO, HMO) Member ID Number Contact Number Primary Care Physician Name Address Phone Number Other Physician(s)

Pharmacy/Drug Store Name of Store Pharmacist Address Phone Number My Allergies (e.g., medications, food)
Be sure to list adverse reactions and side effects caused by allergies

My Medical History
Be sure to include all medical conditions (e.g., illnesses, surgeries).

WHAT YOU SHOULD ASK YOUR DOCTOR

Ask your doctor these questions about your prescription medicines: What is the name of the medicine and what is it supposed to do? How and when should it be taken? How long should I continue to take it? Are there any precautions I should observe while taking the medicine? For example, are there foods or beverages I should avoid while taking the medicine. Any other medicines I should not take? Any limitations on driving vehicles or other activities? What side effects may occur? Are there any serious side effects that should be reported to the doctor? What should I do if minor side effects occur? How long should I wait before reporting to the doctor if my symptoms do not improve? Can the prescription be refilled? Should I check with the doctor before refilling it? Is there any written information available about the drug?

Use this record to keep track of your medicines. Consult your health care provider to make sure the information you provide is accurate. And be sure to provide a family member, and your health care provider and pharmacist with a copy of the information.

Name of Medicine

Dose

Frequency
(how often and when)

Purpose

Directions/Notes

Be sure to include all prescription medicines, over-the-counter drugs, vitamins and herbal supplements. 1 2 3 4 5 6 7