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Bristol-Myers Squibb Patient Assistance Foundation Program for Abilify
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PO Box 8309
Somerville, NJ 08876
Phone
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800-736-0003
Ext 3
Fax:
866-598-5561
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Eligibility
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The patient must have no prescription coverage for any medications. The patient must have an income at or below 250% of the Federal Poverty Level. Medical diagnosis necessary for this program is not specified. The patient must reside in the US, Puerto Rico or the USVI. Medicare Part D enrollees may apply for assistance through a case by case appeals process based on significant financial and medical need. |
| Who Can Apply
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With the patient's permission, anyone concerned can call for an application. |
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Required
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The doctor must fill out a section and sign the application. The patient must fill out a section, sign the application, and attach proof of income. |
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Supply
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Up to a 90-day supply |
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Ship To
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The medication is shipped to the healthcare provider's physical office address. They cannot ship to the patient's home or a PO Box. |
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Note
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
| | Abilify DISCMELT 10mg, 15mg (aripiprazole) | | Abilify Oral Solution 150ml (aripiprazole) | | Abilify Tablets 2mg, 5mg, 10mg, 15mg, 20mg, 30mg (aripiprazole) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | (Requires Acrobat Reader) 
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Bristol-Myers Squibb Destination Access Patient Assistance program for Ixempra
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Erbitux and Ixempra Patient Assistance Program
6900 College blvd, Suite 1000
Overland Park, KS 66211
Phone
:
800-861-0048
Fax:
888-776-2370
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an annual household adjusted gross income of $150,000.00 or less. Medical diagnosis necessary for this program is not specified. The patient must reside in the US, Puerto Rico or the USVI. If the patient has insurance but has been denied coverage for the medication s/he may still be eligible and should contact the company. Decisions are made on a case by case basis. |
| Who Can Apply
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The doctor or patient can call to request an application. |
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Required
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The doctor must fill out a section, sign the application and attach a prescription.The patient must fill out a section, sign the application and attach proof of income and any insurance information. |
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Supply
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Ship To
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The medication is shipped to the doctor's office. Do not provide a PO Box for the shipping address. |
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Note
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The doctor or patient can call to request an application. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
| | Ixempra IV 15mg, 45mg (ixabepilone) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | (Requires Acrobat Reader)
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Bristol-Myers Squibb Access Virology Patient Assistance Program
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6900 College Blvd
Suite 1000
Overland Park, KS 66211
Phone
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888-281-8981
Fax:
888-281-8985
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Eligibility
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The patient must have no prescription coverage for the medication or coverage must have been denied and have an income at or below 300% of the Federal Poverty Level. Medical diagnosis necessary for this program is not specified. The patient must reside in the US, Puerto Rico or the USVI. They may be able to help those who have met their cap and are having difficulty paying for medication. A language line is available. |
| Who Can Apply
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The doctor or patient can call to request an application. |
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Required
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The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income. |
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Supply
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Ship To
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Doctor's office or Patient's home. |
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Note
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The doctor or patient can call to request an application. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
| | Reyataz capsules 100mg, 150mg, 200mg, 300mg (atazanavir sulfate) | | Sustiva Capsules 50mg, 200mg (efavirenz) | | Sustiva Tablets 600mg (efavirenz) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | (Requires Acrobat Reader)
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Bristol-Myers Squibb Patient Assistance Foundation, Inc
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PO Box 1058
Somerville, NJ 08876
Phone
:
800-736-0003
Fax:
800-736-1611
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Eligibility
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The patient must have no prescription coverage for any medications. The patient must have an income at or below 250% of the Federal Poverty Level. Medical diagnosis necessary for this program is not specified. The patient must reside in the US, Puerto Rico or the USVI. Glucophage, Glucophage XR, Glucovance, Metaglip, Monopril, Buspar & Sinemet has been taken off the program. Patients already enrolled in the program receiving these medications will continue to receive the medication(s) as long as s/he is eligible. Medicare Part D enrollees may apply for assistance through a case by case appeals process based on significant financial and medical need. |
| Who Can Apply
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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Required
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The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income. |
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Supply
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Up to a 90-day supply |
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Ship To
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Doctor's office |
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Note
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The patient or doctor must contact the company for refills. Once a year the application process must be repeated. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
| | Avalide Tablets 150mg/12.5mg, 300mg/12.5mg, 300mg/25mg (irbesartan/hydrochlorothiazide) | | Avapro Tablets 75mg, 150mg, 300mg (irbesartan) | | Kombiglyze XR Tablets 5mg/500mg, 2.5mg/1000mg, 5mg/1000mg (saxagliptin/metformin hcl extended-release) | | Onglyza® (saxagliptin) tablets |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | (Requires Acrobat Reader)
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Bristol-Myers Squibb Patient Assistance Foundation for Oncology
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PO Box 991
Somerville, NJ 08876
Phone
:
800-736-0003
Fax:
866-694-2545
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an income at or below 300% of the Federal Poverty Level. Medical diagnosis necessary for this program is not specified. The patient must reside in the US, Puerto Rico or the USVI. Applicants must fill out two forms, one for the patient assistance program and one for benefits investigation. Call 800-861-0048. Medicare Part D enrollees may apply for assistance through a case by case appeals process based on significant financial and medical need. Those receiving Medicare Part D LIS are not eligible. |
| Who Can Apply
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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Required
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The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income and any insurance information. |
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Supply
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Ship To
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Doctor's office |
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Note
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
| | BiCNU Injection 100mg (carmustine) | | CeeNU Capsules 10mg, 40mg, 100mg (lomustine) | | Droxia Capsules 200mg, 300mg, 400mg (hydroxyurea) | | Etopophos Injection 100mg (etoposide phosphate) | | Lysodren Tablets 500mg (mitotane) | | Vumon 50mg/5ml (teniposide) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | (Requires Acrobat Reader)
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Bristol-Myers Squibb Destination Access Patient Assistance Program for Erbitux
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6900 College Blvd
Suite 1000
Overland Park, KS 66211
Phone
:
800-861-0048
Fax:
888-776-2370
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an annual household adjusted gross income of $150,000.00 or less. Medical diagnosis necessary for this program is not specified. The patient must reside in the US, Puerto Rico or the USVI. If the patient has insurance but has been denied coverage for the medication he/she may still be eligible and should contact the company. Decisions are made on a case by case basis. |
| Who Can Apply
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The doctor or patient can call to request an application. |
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Required
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The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income and any insurance information. |
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Supply
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Ship To
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Doctor's office |
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Note
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The doctor or patient can call to request an application. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
| | Erbitux Injection 50ml, 100ml (cetuximab) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | (Requires Acrobat Reader)
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Bristol-Myers Squibb Patient Assistance Foundation Program for Orencia
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PO Box 991
Somerville, NJ 08876
Phone
:
800-736-0003
Fax:
(866)694-2545
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an income at or below 300% of the Federal Poverty Level. Medical diagnosis necessary for this program is not specified. The patient must reside in the US, Puerto Rico or the USVI. |
| Who Can Apply
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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Required
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The patient and healthcare provider must complete and sign the application. The patient must also provide documentation of the annual household income and any insurance information. |
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Supply
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The Doctor’s office needs to contact the company for refills. |
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Ship To
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Product will be shipped to the Doctor’s office or infusion site. |
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Note
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You and your doctor will be notified by mail upon completion of our review and evaluation. Please note that program rules are subject to change without notice. If you have questions or need further assistance, please call (800)736-0003, between 9:00 AM and 6:00 PM Eastern Time, Monday through Friday. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
| | Orencia Injection 250mg/ml (abatacept) | | Orencia Intravenous Infusion |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form Orencia PAP Application | | (Requires Acrobat Reader)
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Bristol-Myers Squibb Destination Access Patient Assistance Program for Sprycel
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6900 College Blvd
Suite 1000
Overland Park, KS 66211
Phone
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(800)861-0048
Fax:
(888)776-2370
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Eligibility
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The patient must have no insurance or have been denied coverage with proof of unsuccessful appeal of denial and have an annual household adjusted gross income of $150,000.00 or less. Medical diagnosis necessary for this program is not specified. The patient must reside in the US, Puerto Rico or the USVI. |
| Who Can Apply
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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Required
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The patient and healthcare provider must complete and sign the application. The patient must also submit proof of income and any insurance information. |
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Supply
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Ship To
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Doctor's office or Patient's home. |
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Note
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We recommend that you return the completed form via fax in order to expedite the process. Once the enrollment form is received, Destination Access will notify the patient’s healthcare provider of the results and any additional assistance options which may be available. Should you have any questions, please call (800) 861-0048. Our customer service administrators are available between the hours of 8:00 AM and 8:00 PM Eastern Standard Time, Monday through Friday (excluding holidays). Please note that Program rules are subject to change without notice. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
| | Sprycel Tablets 20mg, 50mg, 70mg (dasatinib) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | (Requires Acrobat Reader)
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Patient Assistance Foundation Program for Nulojix
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PO Box 991
Somerville, NJ 08876
Phone
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(800)736-0003
Ext 5
Fax:
(866)694-2545
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an annual household adjusted groos income of $75,000 or less. Medical diagnosis necessary for this program is not specified. The patient must reside in the US, Puerto Rico, or the USVI. |
| Who Can Apply
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Anyone requesting assistance can call to request an application or download it from the website. |
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Required
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The doctor must fill out a section and sign the application. The patient must fill out a section, sign the application and attach proof of income and any insurance information. |
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Supply
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Ship To
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Doctor's office |
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Note
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Anyone requesting assistance can call to request an application or download it from the website. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
| | NULOJIX |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | (Requires Acrobat Reader)
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Bristol-Myers Squibb Destination Access Patient Assistance Program for Yervoy
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6900 College Blvd
Suite 1000
Overland Park, KS 66211
Phone
:
(800)861-0048
Fax:
(888)776-2370
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an annual household adjusted gross income of $150,000.00 or less. Medical diagnosis necessary for this program is not specified. The patient must reside in the US, Puerto Rico, or the USVI. If the patient has insurance but has been denied coverage for the medication he/she may still be eligible and should contact the company. Decisions are made on a case by case basis. |
| Who Can Apply
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The doctor or patient can call to request an application. |
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Required
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The doctor must fill out a section and sign the application. The patient must fill out a section, sign the application and attach proof of income and any insurance information. |
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Supply
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Ship To
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Doctor's office |
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Note
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The doctor or patient can call to request an application. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
| | Yervoy Injection |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | (Requires Acrobat Reader)
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Bristol-Myers Squibb Baraclude Patient Assistance Program
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6900 College Blvd.
Suite 1000
Overland Park, KS 66211
Phone
:
(855)898-0267
Fax:
(855)286-6831
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Eligibility
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The patient must have no prescription coverage or been denied coverage, have an income at or below 300% of the FPL, must reside in the US, Puerto Rico or the USVI. |
| Who Can Apply
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The patient or doctor can call for an application. The doctor must complete a section and sign. The patient must complete, sign, and attach proof of income. |
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Required
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Supply
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Not specified. |
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Ship To
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Doctor and Patient are notified of a decision within 24 hours. A card to be used at the pharmacy to obtain medication is activated on the business day following approval into the program. |
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Note
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A new yearly application is required. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
| | Baraclude Oral Solution 210 ml (entecavir) | | Baraclude Tablets 0.5mg, 1mg (entecavir) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | (Requires Acrobat Reader)
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