Micardis® (telmisartan) tablets Program Enrollment Form
IMPORTANT: Please complete all 4 sections in their entirety
o I will mail my prescription
o My doctor will submit my prescription
• Write your date of birth on the original copy of your prescription
• Mail completed Enrol ment Form with your original
• Entire form must still be completed by patient
Door to Door c/o Eagle Pharmacy PO Box 90937
You can also enroll by calling 1-855-900-0785 or visiting www.micardisD2D.com.
• Al ow 5-9 days for delivery fol owing receipt of Enrol ment Form
1. Patient Information
Date of birth (mm/dd/yyyy) _______/_______/_________________ Gender o Male o Female
City________________________________________________________ State__________________ ZIP_____________________
Primary phone number (_______)________________ Email________________________________________________________
Additional Information Do you have any drug al ergies?
o No o Yes If yes, please list (include over-the-counter, herbal, vitamins, etc)
Please list any health conditions: ____________________________________________________________________________________________________________ 2. Insurance Information* (Complete only the fields that apply to your insurance. Secondary insurance is not required.) Primary prescription insurance company name ________________________________________________________________ Name of primary insurance holder ________________________ Relationship to patient _________________________________ Insurance provider phone number (_______)________________ Insured ID _____________________________________________ Benefit identification number (BIN)_________________________ Processor control number (PCN) _______________________ Group name ___________________________________________ Group number ________________________________________ o I do not have prescription insurance, Medicare Part D, Medicaid, or any similar state or federal y funded medical
assistance program. If you do not have insurance, you are still eligible for this program.
3. Payment Information (This section must be completed for your order to be processed.) Credit Card: By providing your credit card information you authorize your credit card to be charged no more than $35* once the final cost of your prescription is determined.
Name on credit card ____________________________________ Credit card number ________________________________
Expiration _____________________________________________ CVC (3-digit code on back, or 4 on front) _______________
Would you prefer to be enrol ed in an automatic refill plan? Please check: o Yes o NoIf so, you are acknowledging that every month we will ship the medication to the address on file and charge the credit card provided the appropriate co-pay.
*See Terms and Conditions on the next page. *Terms and Conditions: Patients must have a valid prescription for Micardis® (telmisartan) tablets.
By enrol ing, I elect to receive the branded product and acknowledge that no generic substitution will be offered (if applicable). Should I wish to receive a generic product in the future, I will call 1-855-900-0785 to opt out of this program. Patients without insurance restrictions and co-pays of $65 or less will pay a $10 co-pay for a one-month supply of MICARDIS. Patients whose co-pay is less than $10 will continue to pay their usual co-pay. For patients whose co-pay is between $65 and $90 they will pay that amount minus the maximum savings benefit of $55 per month. No one will pay more than $35. Patients with insurance restrictions or co-pays of more than $90 will not be processed through insurance and will pay $35 for a one-month supply (30 tablets) of MICARDIS. If you have Medicare Part D, Medicaid or a similar state or federal y funded medical assistance program, you will pay a cash price of $35 for a one-month supply of MICARDIS. All Medicare Part D orders are processed without the use of insurance and cannot be applied to Part D true out of pocket (TrOOP) costs. Taxes may apply. Boehringer Ingelheim Pharmaceuticals, Inc. retains the right to rescind, revoke, or amend this offer at any time without notice. 4. Please Check the Box Below o I agree to the Privacy Statement Policy below and al ow Boehringer Ingelheim to use my information to provide me
with health-related information, useful materials, and offers regarding their products.
This information is being col ected by Boehringer Ingelheim Pharmaceuticals, Inc. so that we may advertise our
products to you and provide you with information about them. We will not share your private information with anyone else—including mailing lists.
We respect your right to have personal medical information kept confidential. Companies working with us will
use the information you provide to send you information, seek your opinions, and help develop products, services, and programs. If we provide you with coupons or vouchers for our products, the information we receive from the pharmacy regarding their use will also be used for the same purposes.
o My doctor will submit my prescription Healthcare Provider Information (Sections 1-4 must still be completed in their entirety by the patient.)
(To be completed by the healthcare provider.)
By fax: • Complete this Enrol ment Form and have your doctor sign it
Full name _____________________________________
• Have your doctor fax the completed form to: 1-855-284-0572
NPI #__________________ Phone ________________
Physician Fax Number __________________________
• Physician: mail completed Enrol ment Form with
patient’s original prescription to Eagle Pharmacy (see address on front)
Strength ________________ Days’ supply _____________
ePrescribing: • Physician: ePrescribe in your system to Eagle Pharmacy Number of refills ______________________________
Date written ____________________________________
Physician signature ________________________________
Please visit www.mymicardis.com for the full Prescribing Information, including Patient Information, for MICARDIS.
Copyright 2014, Boehringer Ingelheim Pharmaceuticals, Inc. All rights reserved. (2/14) MC598809CONS
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