Group # XXXXXXXX
ID# XXXXXXXX
 
 
 
Group # XXXXXXXX
ID# XXXXXXXX

ELIGIBILITY RULES

In order for a patient to qualify for the Co-Pay Assist Program, they must meet the following eligibility criteria established.

Eligibility Requirements

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.

Terms of Use

  • 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. Activation and first use of the Co-pay Card must take place by December 31, 2019.
  • Massachusetts state law prohibits residents the use of this offer for REYATAZ and SUSTIVA due to availability of a generic equivalent.
  • 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.
  • All Program payments are for the benefit of the patient only.
  • 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, M-F) for more information or go to http://www.patientrebateonline.com to download a rebate form.

466US1601585-06-01 05/19 466US1601585-05-01 10/18