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

Program 1 of 7.
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Updated March 11, 2014
Sprycel

BMS Access Support

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

Provided by: Bristol-Myers Squibb Company


TEL: 800-861-0048


ALT PHONE:
FAX: 888-776-2370
Languages Spoken:

English, Others By Translation Service

Program Website
 

Patient Assistance Applications

BMS Reimbursement Support Program for Erbitux

BMS Reimbursement Support Program for Ixempra

BMS Reimbursement Support Program for Sprycel

BMS Reimbursement Support Program for Yervoy

 

Medications

  • Sprycel Tablet 20mg, 50mg, 70mg (dasatinib)
 

Eligibility Requirements

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? Not specified
Income Household income at or less than $150,000
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
Returning Mail or fax
Doctor's Action Complete section, sign
Applicant's Action Complete section, sign, attach proof of income and any insurance information
Decision Communicated Doctor notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Doctor's office
Delivery Time Not specified
Refill Process Doctor/doctor's office must contact company
Limit Not specified
Re-application New application yearly
   

Additional Information

This program is intended for US HEALTHCARE PROFESSIONALS and/or Professionals involved in Healthcare Reimbursement ONLY.



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

Program 2 of 7.
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Updated March 11, 2014
Sprycel

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

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

Provided by: Bristol-Myers Squibb Company

BMSPAF Oncology Patient Assistance
PO Box 991
Somerville, NJ 08876

TEL: 800-736-0003 opt 3


ALT PHONE:
FAX: 888-776-2370
Languages Spoken:

English, Others By Translation Service

Program Website
 

Patient Assistance Applications

BMS Access Support for Erbitux

BMS Access Support for Ixempra

BMS Access Support for Sprycel

BMS Access Support for Yervoy

 

Medications

  • Sprycel Tablet 20mg, 50mg, 70mg (dasatinib)
 

Eligibility Requirements

Insurance Status Must be uninsured or underinsured
Those with Part D Eligible? Yes
Income At or below 300% of FPL
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 to Doctor's office
Returning Fax
Doctor's Action Complete section, sign, attach prescription
Applicant's Action Complete section, sign, attach proof of income and any insurance information
Decision Communicated Doctor notified
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not specified
Sent To Doctor's office
Delivery Time Within 2 business days
Refill Process Refill/reorder form is faxed out 6 weeks after shipment
Limit Not specified
Re-application New application yearly
   

Additional Information

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.

Applicants must call 800-736-0003, option 3 to obtain applications for Droxia, Etopophos, and Lysodren. Applications will be processed by BMS Access Support. 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 7.
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Updated April 11, 2014
Sprycel

Diplomat's Co-Pay Assistance Navigator Program

This is a copay assistance program.

Provided by: Diplomat Specialty Pharmacy

4100 S Saginaw St.
Flint, MI 48507

TEL: 877-977-9118 ext. 89864


ALT PHONE:
FAX: 810-282-0176
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

Diplomat Request of Financial Assistance Form

 

Medications

  • Sprycel Tablet 20mg, 50mg, 70mg (dasatinib)
 

Eligibility Requirements

Insurance Status Determined case by case
Those with Part D Eligible? Yes
Income Determined case by case
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Yes
   

Application

Obtaining Call or complete online
Receiving Faxed, mailed or complete online
Returning Mail or fax
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section, sign and provide annual income information. Proof of income may be request by program at any time
Decision Communicated Patient and/or Doctor are notified
Decision Timeframe Within 1-2 business days
   

Medication

Amount/Supply Amount requested is sent
Sent To Patient's home
Delivery Time Once approved; within 2 business days
Refill Process Company contacts patient to arrange
Limit Varies per medication
Re-application Determined case by case
   

Additional Information

Diplomat Specialty Pharmacy is a full service pharmacy that can help patients seek funding assistance for the copay portion of their required medications. Applications can be completed online or Prescription, Demographics and Proof of Income may be faxed to 810-282-0176 Attn: Dorrie 
Contact program for Spanish application.



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

Program 4 of 7.
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Updated March 04, 2014
Sprycel

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

  • Sprycel Tablet 20mg, 50mg, 70mg (dasatinib)
 

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 5 of 7.
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Updated July 31, 2013
Sprycel

My SPRYCEL Support Program

This is a copay assistance program.

Provided by: Bristol-Myers Squibb Company


TEL: Not Accepting Applications


ALT PHONE: 877-526-7334
FAX: 888-991-2311
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

 

Medications

  • Sprycel Tablet 20mg, 50mg, 70mg (dasatinib)
 

Eligibility Requirements

Insurance Status Must not have public insurance, may have private insurance
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? MA residents are not eligible
   

Application

Obtaining Call for prescreening or apply online
Receiving There is no application
Returning
Doctor's Action Give prescription to patient
Applicant's Action The patient must provide insurance information
Decision Communicated Patient notified
Decision Timeframe Decision made during phone screening
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Within 2 business days
Refill Process Good for one year
Limit Not applicable
Re-application This is a one time program
   

Additional Information

Program is scheduled to close June 30, 2013



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

Program 6 of 7.
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Updated January 30, 2014
Sprycel

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

  • Sprycel Tablet 20mg, 50mg, 70mg, 80mg, 100mg, 140mg (dasatinib)
 

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.



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

Program 7 of 7. Updated February 19, 2014
Sprycel

SprycelOne Co-pay Program

This is a copay assistance program.

Provided by: Bristol-Myers Squibb Company


TEL: 877-526-7334


ALT PHONE:
FAX:
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

 SprycelOne Co-pay Program: Contact program

 

Medications

  • Sprycel Tablet 20mg, 50mg, 70mg (dasatinib)
 

Eligibility Requirements

Insurance Status Must have insurance
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Not specified
   

Application

Obtaining Call for prescreening or apply online
Receiving Not applicable
Returning Not applicable
Doctor's Action Not applicable
Applicant's Action The patient responds to questions over the phone to verify eligibility
Decision Communicated Not specified
Decision Timeframe Varies
   

Medication

Amount/Supply Not applicable
Sent To Patient's home
Delivery Time Not specified
Refill Process Not applicable
Limit Not specified
Re-application Must re-enroll at end of calendar year
   

Additional Information

The company will cover any copay costs over $25 per month and up to $25,000 per calendar year. The patient must use a participating specialty pharmacy.