Bristol Myers Squibb is committed to helping appropriate patients get access to our medications by providing access and reimbursement support services.

This information is intended for U.S. healthcare professionals and/or healthcare professionals involved in healthcare reimbursement.

< Back
Medication Selector >

Forms and Resources

< Back
Medication Selector >

Forms and Resources

Local Care Resources for
Your Patients

Help patients find transportation, medical services, care at home, and other local healthcare-related resources.

Formulary Large Icon Go to Patient Resource Connections
See Payer Policy Details

Learn about payer information by state for applicable treatments

Formulary Large Icon Start Here >

Video Resources

Looking for insurance information, helpful tools, or answers to common coverage questions? We’ve provided the following videos for healthcare providers and their patients.

Forms and Documents

Select a medication for specific medication enrollment forms and documents here.

To enroll or conduct a Benefits Review, please visit this site from your desktop computer.

Claim Documents

Blank CMS-1500 Form
Download

Blank UB-04/CMS-1450 Form
Download

Office Support Tools

Peer-to-Peer Medical Checklist
Download

Patient Benefits Information Form
Download

Medically Unlikely Edit (MUE) Appeal Template Letter
Download

Medical Necessity Template Letter*
Download

Letter of Medical Necessity Checklist
Download

Prior Authorization Denial/Redetermination Appeal Template Letter*
Download

Commercial Claim Denial Appeal/Redetermination Template Letter*
Download

Open Access Template Letter*
Download

My BMS Cases User’s Guide
Download

HCP Reimbursement Process Map
Download

*Template letters are provided as examples of potential correspondence.

CMS Forms and Documents

Medicare Redetermination Request Form (Form CMS-20027)
Download

Medicare Reconsideration Request Form (Form CMS-20033)
Download

Request for a Medicare Hearing by an Administrative Law Judge (Form CMS-20034A/B)
Download

Medicare Appointment of Representative Form (Form CMS-1696)
Download

Patient Resources

Understanding Your Healthcare Benefits
Download

Patient Brochure
Download

Patient Reimbursement Process Map
Download

The accurate completion of reimbursement- or coverage-related documentation is the responsibility of the healthcare provider and patient. Bristol Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.

Support Center icon
Support Center: 1-800-861-0048
8 am to 8 pm ET, Mon - Fri
Schedule a Call icon
Schedule a call from a Patient Access SpecialistSchedule a Call >
Request a Visit icon
Request a visit from a BMS Access & Reimbursement ManagerRequest a Visit >
Schedule a Call > Request a Visit >
Bristol-Myers Squibb logo

©2022 Bristol-Myers Squibb Company. Access Support is a registered trademark of Bristol-Myers Squibb Company.

Use of the information on this site is subject to the terms of our Legal Notice and Privacy Statement. The coding, coverage, and payment information contained within this website is current as of 04/22.

NO-US-2103027 04/22