Here’s how the Co-Pay Assist Program Works:
If you have commercial insurance, including insurance purchased through the Affordable Care Act Exchange plans, Bristol-Myers Squibb may be able to help pay the out-of-pocket expenses (co-pay, co-insurance, deductibles) of your prescription (for those products listed on the card). If you are eligible, up to $7,500 per product per year will be provided; you will be responsible for any out-of-pocket expenses over $7,500.
This program is not available for patients who are enrolled in government healthcare prescription drug programs, such as Medicare Part D, Medicaid, VA, DOD, or TriCare.
For patients who would like to receive co-pay assistance through a mail order pharmacy or if your pharmacy does not participate with this program, please click the button to the left to download a rebate form or call 1-866-566-6446 (8 AM - 8 PM ET, M-F) for more information.
For other cardholder questions, call 1-888-281-8981.
You may be eligible for the Co-Pay Assist Program if:
- You are insured by commercial insurance and your insurance coverage does not cover the full cost of your prescription, that is, you have a co-pay obligation.
- You are not enrolled in any state or Federal Healthcare Prescription Program, including but not limited to Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA) or Department of Defense (DOD) programs. Patients who move from commercial to state or Federal Healthcare Program will no longer be eligible.
- You are a resident of Puerto Rico or the United States.
- Eligible patients must present activated Co-Pay Assist Card or Member Identification Number with valid prescription for covered products at time of purchase to receive out-of-pocket assistance.
- Out-of-pocket benefit equals an amount up to $7,500 annually for each product covering the following: EVOTAZ, REYATAZ or SUSTIVA. Patient is responsible for applicable taxes, if any.
- If a patient reaches the maximum annual benefit of $7,500, the patient will be responsible for the outstanding balance.
- Patients may get a 30-, 60- or 90-day supply of unlimited fills.
- Patients who utilize mail order may also be eligible for co-pay assistance.
- Patients, pharmacists and prescribers cannot seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this offer.
- Your acceptance of this offer confirms that this offer is consistent with your insurance and that you will report the value received as may be required by your insurance provider.
- Card must be activated before use, and expires on December 31, 2018.
- Only valid in the United States or Puerto Rico; this offer is void where restricted or prohibited by law.
- Card is limited to 1 per patient for the life of the program and is not transferable.
- The Co-Pay Assist Card may not be sold, purchased, traded or counterfeited. Reproductions of this Co-Pay Assist Card are void.
- Bristol-Myers Squibb Company reserves the right to rescind, revoke or amend this offer at any time without notice.
- No membership fees.
- The Co-Pay Assist Card is not insurance.
- For most eligible, commercially-insured patients who would like to receive co-pay assistance through a mail order pharmacy or if your pharmacy does not participate with this program, please call 1-866-566-6446 (8 AM - 8 PM ET, M-F) for more information or go to www.patientrebateonline.com to download a rebate form.
To the Pharmacist:
When you use this card, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state or other governmental programs for this prescription.
- For questions regarding setup, claim transmission, patient eligibility or other issues, call the LoyaltyScript® for the Co-Pay Assist program at 1-877-264-2440 (8:00 AM-8:00 PM ET, Monday-Friday).
- Submit transaction to McKesson Corporation using BIN #610524.
- If primary coverage exists, input card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response.
- Acceptance of this card and your submission of claims for the Co-Pay Assist program are subject to the LoyaltyScript® program Terms and Conditions posted at www.mckesson.com/mprstnc.
- Patient is not eligible if prescriptions are paid in part or full by any state or federally funded programs, including but not limited to Medicare or Medicaid, Medigap, VA, DOD or TriCare and where prohibited by law.