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      Patient Assistance Program Center

Program Details

Bristol-Myers Squibb Patient Assistance Foundation Inc.

Eliquis (apixaban)
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 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: Single 300 % FPL
      Couple 300 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    Attachments Required: Financial
    Physician License #
    Prescriber Signature
    Application may be
    Eligibility determination
    letter sent:
    Both Provider and Patient
    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: 10/19/2021




    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


    Print-friendly version

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