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| Program Contact Info / Application Submission | ||||||||||||||||||||
| Program | Bristol-Myers Squibb Patient Assistance Foundation, Inc. (Abilify) | |||||||||||||||||||
| Company | BrisMyrAbilify | |||||||||||||||||||
| Form | Download PDF | |||||||||||||||||||
| Address | PO Box 8309 Somerville, NJ 08876 | |||||||||||||||||||
| Phone | 800-736-0003, opt 3 | |||||||||||||||||||
| Fax | 866-598-5561 | |||||||||||||||||||
| Program Details | ||||||||||||||||||||
| Details | Up to a 90-day supply is sent to the doctor's office. The patient or doctor must contact the company for refills. Every year a new application is needed | |||||||||||||||||||
| Program Requirements | ||||||||||||||||||||
| Information | The doctor must fill out a section and sign the application. The patient must fill out a section, sign the application, and attach proof of income and any denial letters from insurance companies | |||||||||||||||||||
| Details | Insurance card required Drivers license NOT required Proof of Income required Copy of most recent tax return such as 1040, 1099 required as proof of income Letter from Doctor stating zero income required as proof of income Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements required as proof of income Most recent check/check stub copy required as proof of income Letter from employer required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement required as proof of income Award Letter for Alimony/Child Support, Unemployment required as proof of income Notarized statement from patient stating zero income required as proof of income | |||||||||||||||||||
| Delivery of Medication | ||||||||||||||||||||
| Ship Time | 3-5 Business days | |||||||||||||||||||
| Delivery Options | Can NOT be delivered directly to the patient Can be delivered directly to the doctor | |||||||||||||||||||
| Application Process | ||||||||||||||||||||
| App Process | With the patient's permission, anyone concerned can call for an application. The application will be faxed out. The completed application can be faxed or mailed back. Both the patient and doctor are notified in writing of acceptance or denial. The decision is usually made within 48 hours. The medication is shipped the next day. | |||||||||||||||||||
| New Applications | New applications accepted Patients can apply directly to the program Doctors can apply directly to the program Advocates can apply directly to the program Can NOT apply for a new application via phone Can apply for a new application via fax Can apply for a new application via mail | |||||||||||||||||||
| Refills | Refills accepted Patients can apply for refills Doctors can apply for refills Advocates can apply for refills Can NOT apply for refills via phone Can apply for refills via fax Can apply for refills via mail | |||||||||||||||||||
| Re-Applications | Re-Applications accepted Patients can apply for Re-Applications Doctors can apply for Re-Applications Advocates can apply for Re-Applications Can NOT Re-Apply via phone Can Re-Apply via fax Can Re-Apply via mail | |||||||||||||||||||
| Appeals | Income Appeals accepted Patients can apply for Income Appeals Doctors can apply for Income Appeals Advocates can apply for Income Appeals Hardship Appeals accepted Patients can apply for Hardship Appeals Doctors can apply for Hardship Appeals Advocates can apply for Hardship Appeals Can NOT apply for an appeal via phone Can apply via fax Can apply for an appeal via mail | |||||||||||||||||||
| Eligibility | ||||||||||||||||||||
| Eligibility | The patient cannot have prescription insurance, be ineligible for any federal or state programs and meet income guidelines that are not disclosed. The patient must also be a US citizen. If a patient enrolls in Medicare Part D, then s/he is no longer eligible for this program. If the patient chooses not to to enroll in Part D then s/he is still eligible to be on this program. | |||||||||||||||||||
| Limitations | Patients are eligible if LIS is denied Patients are NOT eligible with existing prescription coverage Patients are NOT eligible if prescription is not covered Patients are NOT eligible if prescription coverage has been exhausted Patients are eligible if they are accepting Medicare Patients are eligible if they are accepting Medicare part D Patients are eligible if the medication is not covered under Medicare Patients are eligible if Medicare coverage has been exhausted | |||||||||||||||||||
| Appeals | ||||||||||||||||||||
| Conditions | Appeals will consider out-of-pocket expenses Appeals will consider total medical expenses Appeals must be made after the patient has been denied | |||||||||||||||||||
| Other Medications | ||||||||||||||||||||
| Other Medications available in this program |
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