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

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

  • apixaban tablet (Eliquis) Tablet
 

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 October 12, 2017