ERBITUX® (cetuximab) Patient Assistance

• The Destination Access ERBITUX Patient Assistance Program provides free ERBITUX to eligible patients with an on-label or compendia-listed tumor diagnosis, and an annual household adjusted gross income of $75,000 or less
• There is an annual enrollment period, during which treatment must be ongoing and provided on an outpatient basis
• Patients treated with ERBITUX who have received a denial of a Level 2 appeal, or who have reached the maximum level of denied appeals from their health insurer, may elect to apply for patient assistance or continue with the appeals process  
• If the patient is approved for the Destination Access ERBITUX Patient Assistance Program, the physician will be shipped ERBITUX on the next business day (excluding weekend delivery unless specifically requested) for the patient’s next scheduled treatment date. Product refills for future treatments may be obtained by faxing the completed refill form and chemo flow sheets to Destination Access on a monthly basis, prior to the next scheduled treatment date. Refill forms may be obtained by clicking on the link below
  • Destination Access ERBITUX Refill Form
• Physicians’ practices may be eligible for a refund for the cost of ERBITUX treatments administered 60 days prior to the patient’s enrollment date into the Patient Assistance Program for uninsured patients treated for on-label or a compendia-listed indication. Physicians’ practices may be eligible to receive a refund for the cost of unreimbursed prior ERBITUX treatments for insured patients who have received a denial of a Level 2 appeal from their health insurer, or who have reached the maximum level of denied appeals  

There are 3 steps to the Destination Access ERBITUX Patient Assistance Program application process:

1. The patient and healthcare provider complete the application provided in the
   link below. An application may also be obtained by calling Destination Access at
   1-800-861-0048, Monday–Friday, 7:00 AM - 7:00 PM CST. 
   
   Download ERBITUX Enrollment Form
   
   
2. If the patient would like to be considered for patient assistance, please include a photocopy of the patient’s proof of annual household income and chemo flow sheets with the application. Examples of proof of income include: Federal tax return, social security or retirement income statements. Please fax the completed and signed application, along with proof of income documentation and chemo flow sheets to Destination Access at: 1-888-776-2370.
   
   
3. A Destination Access program specialist will contact the patient’s healthcare provider on or before the next business day to discuss the options available to the patient, including if the patient qualifies to receive free ERBITUX through the Destination Access ERBITUX Patient Assistance Program.



4. If it is determined that the patient qualifies for patient assistance, the patient’s healthcare provider will be contacted within the next business day by a Destination Access program specialist to initiate product shipment. For more information about Destination Access ERBITUX, please call 1-800-861-0048, Monday–Friday, 7:00 AM - 7:00 PM CST.

• U.S. Citizen or U.S. Legal Resident Alien status
• Household annual adjusted gross income must not exceed $75,000
• ERBITUX is prescribed for an FDA-approved or compendia-accepted diagnosis
• Uninsured patients or insured patients, who have received a Level 2 appeal denial from their health insurer and have elected not to continue the appeals process; or who have reached the maximum level of denied appeals
• Treatment is ongoing and administered on an outpatient basis

Uninsured Patients:

• Physicians may be eligible for refunding for the cost of ERBITUX treatments administered 60 days prior to the patient’s approval date into the Destination Access ERBITUX Patient Assistance Program
• Upon enrollment into the Destination Access ERBITUX Patient Assistance Program, a Destination Access counselor will contact the patient’s healthcare provider if the cost of the patient’s prior ERBITUX treatments may be eligible for refunding. The healthcare provider will be faxed a refunding application form, including a detailed explanation of the information needed to qualify for refunding
• Once the patient’s healthcare provider faxes the required information to Destination Access, the information will be forwarded to Bristol-Myers Squibb for processing. On average, if the healthcare provider qualifies for a refund, the provider should anticipate receiving a refund check within 90 days from the date all required information was submitted to Destination Access

Insured Patients:

• Physicians may be eligible to receive a refund for the cost of unreimbursed ERBITUX treatments administered to patients with on-label or compendia-listed diagnosis, who have received denial of a Level 2 appeal by their insurance carrier or who have reached the maximum level of denied appeals
• The patient and healthcare provider should complete the Destination Access ERBITUX Application Form and fax it to Destination Access
• Once the patient receives an initial denial from the health insurer for a Level 2 appeal for ERBITUX, the patient’s healthcare provider should contact Destination Access to let them know if the patient would like to apply for the Destination Access ERBITUX Patient Assistance Program. If the patient qualifies, the patient’s healthcare provider may qualify for refunding of the cost of any unreimbursed ERBITUX treatments
• If a patient is no longer on therapy, but has received a denial of a Level 2 appeal from their health insurer for ERBITUX, or has reached the maximum number of denied appeals, the physician may still qualify for refunding for the cost of any unreimbursed ERBITUX treatments
• The healthcare provider will be faxed a refunding application form, including a detailed explanation of the information needed to qualify for a refund

Once the patient’s healthcare provider faxes all of the requested information to Destination Access, the information will be forwarded to Bristol-Myers Squibb for processing. On average, if the healthcare provider qualifies for a refund, the provider should anticipate receiving a refund check within 90 days from the date all required information was submitted to Destination Access.       

To learn more about how refunding works, please contact Destination Access at 1-800-861-0048, Monday–Friday, 7:00 AM - 7:00 PM CST; Fax: 1-888-776-2370.