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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.
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| Sprycel Tablets 20mg, 50mg, 70mg (dasatinib) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
(Requires Acrobat Reader) 
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Patient Access Network Foundation (PAN)
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PO Box 221858
Charlotte, NC 28222
Phone
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(866)316-7263
Fax:
(866)316-7263
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Eligibility
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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
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Patients or healthcare providers can complete the application online or by phone. |
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Required
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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. |
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Supply
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Not applicable |
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Ship To
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Patient sent card to be used at pharmacy |
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Note
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*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.
|
| Sprycel Tablets 20mg, 50mg, 70mg (dasatinib) |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
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