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Patient Assistance Information

 
 
 
Bristol-Myers Squibb Destination Access Patient Assistance Program for Sprycel

6900 College Blvd
Suite 1000
Overland Park, KS 66211
Phone : (800)861-0048
Fax: (888)776-2370
Eligibility
> The patient must have no insurance or have been denied coverage with proof of unsuccessful appeal of denial 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.
Who Can Apply
> Anyone requesting assistance can call to request a faxed application or download it from the website.
Required
> The patient and healthcare provider must complete and sign the application. The patient must also submit proof of income and any insurance information.
Supply
>
Ship To
> Doctor's office or Patient's home.
Note
> We recommend that you return the completed form via fax in order to expedite the process. Once the enrollment form is received, Destination Access will notify the patient’s healthcare provider of the results and any additional assistance options which may be available. Should you have any questions, please call (800) 861-0048. Our customer service administrators are available between the hours of 8:00 AM and 8:00 PM Eastern Standard Time, Monday through Friday (excluding holidays). Please note that Program rules are subject to change without notice.
 
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.
 
Sprycel Tablets 20mg, 50mg, 70mg (dasatinib)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader