Don't qualify for this program?
Visit the DBAs to look for financial assistance based on your diagnosis.

Program 1 of 4.
Scroll down to see them all.
Updated April 16, 2012
Nulojix

Bristol-Myers Squibb Patient Assistance Foundation: Nulojix Patient Assistance Program

This program provides brand name medications at no or low cost.

Provided by: Bristol-Myers Squibb Company

PO Box 991
Somerville, NJ 08876

TEL: 800-736-0003, opt 5


ALT PHONE:
FAX: 866-694-2545
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website
 

Patient Assistance Applications

 

Medications

  • Nulojix Injection 250mg (belatacept)
 

Eligibility Requirements

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? Yes
Income Household income at or less than $75,000
Diagnosis/Medical Criteria Not specified
US Residency Required? Must reside in the US, Puerto Rico or the USVI
   

Application

Obtaining Call or download
Receiving Faxed or mailed
Returning Mail or fax
Doctor's Action Complete section, sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Doctor notified via mailed letter
Decision Timeframe Not specified
   

Medication

Amount/Supply Amount requested is sent
Sent To Doctor's office or infusion site
Delivery Time Not specified
Refill Process Doctor/doctor's office must contact company
Limit None
Re-application New application every 12 months
   

Additional Information




Don't qualify for this program?
Visit the DBAs to look for financial assistance based on your diagnosis.

Program 2 of 4.
Scroll down to see them all.
Updated April 15, 2014
Nulojix

Bristol-Myers Squibb Patient Assistance Foundation

This program provides brand name medications at no or low cost.

Provided by: Bristol-Myers Squibb Company

PO Box 220769
Charlotte, NC 28222-0769

TEL: 800-736-0003


ALT PHONE:
FAX: 800-736-1611
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website
 

Patient Assistance Applications

Bristol-Myers Squibb Patient Assistance Foundation

 

Medications

  • Nulojix Injection 250mg (belatacept)
 

Eligibility Requirements

Insurance Status Must have no prescription coverage
Those with Part D Eligible? Considered on exception basis
Income At or below 250% of FPL
Diagnosis/Medical Criteria Medication must be for outpatient use only
US Residency Required? Must reside in the US, Puerto Rico or the USVI
   

Application

Obtaining Call or download
Receiving Faxed
Returning Mail or fax
Doctor's Action Complete section, sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within a week
   

Medication

Amount/Supply Varies
Sent To Doctor's office
Delivery Time Within 5-7 business days
Refill Process Doctor/doctor's office must contact company
Limit None
Re-application New application yearly
   

Additional Information

Contact program for Spanish application.



Don't qualify for this program?
Visit the DBAs to look for financial assistance based on your diagnosis.

Program 3 of 4.
Scroll down to see them all.
Updated March 04, 2014
Nulojix

HealthWell Foundation Copay Program

This is a copay assistance program.

Provided by: HealthWell Foundation

P.O Box 4133
Gaithersburg, MD 20897-7811

TEL: 800-675-8416


ALT PHONE:
FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website
 

Patient Assistance Applications

Reimbursement Request Form - Copayment Assistance

 

Medications

  • Nulojix Injection 250mg (belatacept)
 

Eligibility Requirements

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Less than 400% of FPL.may qualify. Cost of living in a particular city or state is considered.
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Must reside in the US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Mail
Doctor's Action Complete section, sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months
   

Additional Information

This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease.

Call for most recent medications as the list is subject to change.



Don't qualify for this program?
Visit the DBAs to look for financial assistance based on your diagnosis.

Program 4 of 4. Updated January 30, 2014
Nulojix

Patient Access Network Foundation

This is a copay assistance program.

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


ALT PHONE:
FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website
 

Patient Assistance Applications

PAN Brochure

PAN Eligibility Criteria and Benefit Cap Information

PAN Proof of Expenditure Form

 

Medications

  • Nulojix Injection 250mg (belatacept)
 

Eligibility Requirements

Insurance Status Must have insurance
Those with Part D Eligible? Determined case by case
Income At or below 500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Fax, mail or submit online
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section, sign
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved ; shipped same day.
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

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.