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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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