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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.
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| Abilify DISCMELT 10mg, 15mg (aripiprazole) |
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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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