Co-Pay Assist PROGRAM

Covering up to the first $400 per monthly co-pay for a year*

* Subject to eligibility criteria/restrictions below

$0 Co-Pay* for most eligible patients

How the Co-Pay Assist Program Works

For eligible patients, Bristol-Myers Squibb will help pay for the cost of prescription co-pays for the products listed on the card—up to $400 per co-pay per product for a maximum of 12 monthly co-pays within 1 year. If the total cost of your co-pay is over $400, you will be responsible for the outstanding balance.

Saving with Your Co-Pay Assist Card

How To Get Started:

Eligibility Requirements

You may be eligible for the Co-Pay Assist Program if:

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 co-pay assistance.
  • Co-pay assistance benefit equals an amount up to $400 per each co-pay of ATRIPLA, REYATAZ or SUSTIVA up to 12 monthly co-pays within 1 year. Patient is responsible for applicable taxes, if any.
  • If the total cost of the patient’s co-pay is over $400 for a 30 day supply, the patient will be responsible for the outstanding balance.
  • Patients may get a 30, 60 or 90 day supply and may be eligible for up to $400 of co-pay assistance per 30 day supply.
  • Patients may not be eligible for the full co-pay benefit of $400 for certain doses of SUSTIVA 50- and 200-mg capsules.
  • 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 use of the Co-pay Assist card must take place by December 31, 2014. This program expires on December 31, 2014.
  • 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 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 888-281-8981 for more information.

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.

  • 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
  • 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.
  • For questions regarding setup, claim transmission, patient eligibility or other issues, call the LoyaltyScript® for the Co-Pay Assist program at 877-264-2440 (8:00 AM-8:00 PM EST, Monday-Friday).

REYATAZ, SUSTIVA, and the SUSTIVA logo are registered trademarks of
Bristol-Myers Squibb Company. ATRIPLA is a registered trademark of Bristol-Myers Squibb &
Gilead Sciences, LLC.

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