Eliquis Patient Assistance Form Printable There is no charge to submit your application form TO APPLY COMPLETE THIS FORM AND APPLICATION FORM The Bristol Myers Squibb Patient Assistance Foundation Inc BMSPAF is a non profit organization that seeks to help eligible patients get the following medicines for free
For more information about how insurance covers ELIQUIS and co pay assistance for eligible commercially insured patients visit ELIQUIS patient support or call 855 354 7847 Assistance for Uninsured Patients Do you need help paying for your Bristol Myers Squibb medicines You may qualify for the BMSPAF program if you have an annual household income of 40770 or less and meet other criteria Find out how to apply and what documents you need on this webpage
Eliquis Patient Assistance Form Printable
Eliquis Patient Assistance Form Printable
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HEALTHCARE PROVIDER REQUIREMENTS Complete and sign Healthcare Provider Information section Complete the section for RX instructions including drug name strength and quantity per day see drug list List a shipping address of an authorized healthcare facility Product will not be shipped to a patient s home or to a PO Box
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Eliquis Patient Assistance Form Printable
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https://www.eliquis.ca/assistancecard
SAVINGS FOR BRAND NAME ELIQUIS With the ELIQUIS Payment Assistance Card get your brand name ELIQUIS at little to no extra cost over the generic When you pick up your prescription just show your ELIQUIS Payment Assistance Card and start saving All fields are required
https://www.eliquis.com/eliquis/hcp/resources
Co pay assistance for eligible patients prescribed ELIQUIS This co pay card is accepted only at participating pharmacies This co pay card is not health insurance Eligibility Requirements and Terms and Conditions apply Please see drop downs below for details
https://www.eliquis.ca
Our Payment Assistance Card can help you get your original brand name ELIQUIS at little to no extra cost over the generic State your preference for original brand ELIQUIS If it s not in stock you can have the pharmacy order it or you can try another pharmacy
https://forms.benefitscheckup.org/bristol_myers_pap_applicati…
BMSPAF may change or stop the program at any time without notice Print Patient Name Patient Signature Date 3 NOUS1605483 11 16
https://www.eliquis.com/eliquis/servlet/servlet.FileDownload?fil…
Print name of Patient or Personal Representative Description of Personal Representative Authority Zip Preferred Email Address Phone Patient Date of Birth The patient or his her personal representative must be provided with a copy of both pages of this form after it has been signed
24 times Expires December 31 2024 Form more information phone 855 354 7847 or Visit website Eliquis FREE 30 day Trial Eigivle patients may receive a FREE 30 day supply up to 74 tablets limited to one use per patient per lifetime for additional information contact the program at 855 354 7847 Applies to Eliquis Let s rapidly go through them so that you can stay certain that your eliquis patient assistance form printable remains protected as you fill it out SOC 2 Type II and PCI DSS certification legal frameworks that are established to
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