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Program Details

BRISTOL-MYERS SQUIBB
Bristol-Myers Squibb Patient Assistance Foundation Inc.
Abilify (aripiprazole)
 
CONTACT INFO
Address: PO Box 220769
Charlotte, NC 28222-0769
Phone: 1-800-736-0003 Provider Phone:
Fax: 1-800-736-1611 Website: Bristol-Myers Squibb Assistance Foundation Website
ELIGIBILITY
Eligibility Info:
  • Patient must not have insurance coverage and is being treated as an outpatient for one of the medications listed on application.
  • Patients with Medicare Part D must have spent at least 3% of yearly household income on out-of-pocket costs for prescriptions this year.
    		•
    Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Physician License #
    Required:    		 State
    NPI
    Prescriber Signature
    Allowed:    		 Physician
    Application may be
    faxed:    		 Yes
    Eligibility determination
    letter sent:    		 Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment: Amount varies
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Refill Policy: The patient or doctor must contact the company for refills.
    Other Information:

    Last Updated: 02/28/2024

    		  

     

     


    Application Forms
    & Instructions
    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)


    Document Zeposia Application


    Document Camzyos Application

     

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