Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 3.
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Nulojix

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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


FAX: 800-736-1611
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Bristol-Myers Squibb Patient Assistance Foundation Application

 

Medications

  • Nulojix injection (belatacept)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage
Those with Part D Eligible? Considered on exception basis
Income At or below 300% 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 Fax or mail
Doctor's Action Complete section and 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


Updated June 02, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
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Nulojix

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BMS Access Support Kidney Transplant Support

This is a copay assistance program.

Provided by: Bristol-Myers Squibb Company

Kidney Transplant Reimbursement Support
PO Box 221509
Charlotte, NC 28222-1509

TEL: 800-861-0048


FAX: 888-776-2370
Languages Spoken:

English

Program Website

 

Program Applications and Forms

BMS Access Support Kidney Transplant Support Enrollment Form

 

Medications

  • Nulojix (belatacept)
 

Eligibility Requirements   

Insurance Status Must be commercially insured
Those with Part D Eligible? No
Income Not applicable
Diagnosis/Medical Criteria Must be 18 yr old or older
US Residency Required? Must be residing in the US or Puerto Rico
   

Application

Obtaining Call or download
Receiving Downloaded from website
Returning Fax from Doctor's office
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section and sign
Decision Communicated Doctor notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Up to two years
Re-application Must re-enroll at end of calendar year
   

Additional Information


Updated June 13, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 3.
 

Nulojix

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HealthWell Foundation Copay Program

This is a copay assistance program.

Provided by: HealthWell Foundation

PO Box 4133
Gaithersburg, MD 20897-7811

TEL: 800-675-8416


FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

 HealthWell Foundation Copay Program: Contact program

 

Medications

  • Nulojix (belatacept)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
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 and 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.
Updated May 10, 2016