Registered Users Log-in:

E-mail Address:
 

Password:
 

  
Forgot Password?
Registration
 
Patient Assistance Information

 
1 Program for ONGLYZA®
 
 
Bristol-Myers Squibb Patient Assistance Foundation, Inc

PO Box 1058
Somerville, NJ 08876
Phone : 800-736-0003
Fax: 800-736-1611
Eligibility
> 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
> 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.
Supply
> Up to a 90-day supply
Ship To
> Doctor's office
Note
> The patient or doctor must contact the company for refills. Once a year the application process must be repeated.
 
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.
 
Onglyza® (saxagliptin) tablets
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader