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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
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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 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.
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| Yervoy Injection |
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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.
|
| Yervoy Injection |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
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