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Bristol-Myers Squibb Patient Assistance Foundation for Oncology
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PO Box 991
Somerville, NJ 08876
Phone
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800-736-0003
Fax:
866-694-2545
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an income at or below 300% 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. Applicants must fill out two forms, one for the patient assistance program and one for benefits investigation. Call 800-861-0048. Medicare Part D enrollees may apply for assistance through a case by case appeals process based on significant financial and medical need. Those receiving Medicare Part D LIS are not eligible. |
| 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 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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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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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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| BiCNU Injection 100mg (carmustine) |
| CeeNU Capsules 10mg, 40mg, 100mg (lomustine) |
| Droxia Capsules 200mg, 300mg, 400mg (hydroxyurea) |
| Etopophos Injection 100mg (etoposide phosphate) |
| Lysodren Tablets 500mg (mitotane) |
| Vumon 50mg/5ml (teniposide) |
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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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