| Pharmaceutical Company | Bristol-Myers Squibb |
| Program Address | Bristol-Myers Squibb Patient Assistance Foundation PO Box 2118 Lakewood NJ 08701 |
| Toll Free Phone Number | 800-736-0003 |
| Fax Number | 800-736-1611 |
| Guidelines and Notes | Call Monday through Friday 9-6PM Eastern Time. There is a separate program for their oncology. Patient must be a US Citizen or legal resident alien. The form is pretty simple. Physician and patient are notified regarding acceptance or denial of application. The address on the form must be the same as the address listed with the DEA number of the prescriber. |
| Initiating Enrollment | Doctor or patient can call for form which will be automatically faxed 24 hours a day, or it can be printed out from this site. Application can be mailed or faxed. |
| Health Provider's Role | Doctor completes physician section which includes DEA# and signs form including the RX section which takes the place of a prescription. There is a list of drugs and the "NDC Number" for the drug must be on the form as well as the name of the drug. |
| Patient's Role | Provide basic information including gross monthly income and size of household, and whether or not patient has public or private prescription insurance and sign form. |
| How Dispensed | Medication sent to the prescriber. |
| Amount Dispensed | Once approved, patient can get up to a 1 year supply of medication. |
| Refills | A new form can be used to change the dosage for an existing patient; the physician would indicate that on the prescription section of the form.. |
| Limit | Indefinitely |