BMS Access Support^® offers both online and fax enrollment.

Start here to conduct a benefits review, initiate assistance with prior authorizations and appeals, and request financial support program enrollment for eligible patients. Once the enrollment form has been submitted and a benefits review has been conducted, you will receive your patient’s summary of healthcare benefits.

Fax Enrollment

Fax Enrollment

If you prefer to manually complete the enrollment process, please download the appropriate enrollment form below based on the product your patient has been prescribed and fax the completed form to the number listed on the form.

Download form for:

AUGTYRO™ (repotrectinib)

EMPLICITI^® (elotuzumab)

OPDIVO^® (nivolumab) and OPDIVO Combination

OPDUALAG^™ (nivolumab and relatlimab-rmbw)

SPRYCEL^® (dasatinib)

YERVOY^® (ipilimumab)

English Spanish

Download form for:

ABRAXANE^® (paclitaxel protein-bound particles for injectable suspension) (albumin-bound)

IDHIFA^® (enasidenib)

INREBIC^® (fedratinib)

ISTODAX

ONUREG^® (azacitidine)

POMALYST^® (pomalidomide)

REBLOZYL^® (luspatercept-aamt)

REVLIMID^® (lenalidomide)

THALOMID^® (thalidomide)

VIDAZA

English Spanish

Download form for:

NULOJIX^® (belatacept)

English Spanish

Note, a completed form requires signatures from both physician AND patient. Completed forms should be faxed to the number provided on the form.

If your office prefers to complete enrollment manually via fax but your patient is not present, patients can sign their Patient Authorization and Agreement form electronically. Visit the patient e-signature portal.