Registered Users Log-in:

E-mail Address:
 

Password:
 

  
Forgot Password?
Registration
 
Patient Assistance Information

 
2 Programs for Etopophos (etoposide phosphate)
 
 
Bristol-Myers Squibb Patient Assistance Foundation for Oncology

PO Box 991
Somerville, NJ 08876
Phone : 800-736-0003
Fax: 866-694-2545
Eligibility
> 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
> Anyone requesting assistance can call to request a faxed application or download it from the website.
Required
> 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.
Supply
>
Ship To
> Doctor's office
Note
> Anyone requesting assistance can call to request a faxed application or download it from the website.
 
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.
 
Etopophos Injection 100mg (etoposide phosphate)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
Patient Access Network Foundation (PAN)

PO Box 221858
Charlotte, NC 28222
Phone : (866)316-7263
Fax: (866)316-7263
Eligibility
> This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US.
Who Can Apply
> Patients or healthcare providers can complete the application online or by phone.
Required
> Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received.
Supply
> Not applicable
Ship To
> Patient sent card to be used at pharmacy
Note
> *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.
 
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.
 
Etopophos Injection 100mg (etoposide phosphate)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader