Kombiglyze XR

Indicated For

Type 2 Diabetes

About This Medication

# Bristol-Myers Squibb Patient Assistance Foundation, Inc. Patient Guide: How to Get **Kombiglyze XR** at Low or No Cost This guide explains the **Bristol-Myers Squibb Patient Assistance Foundation, Inc.** (BMSPAF) program, which provides **Kombiglyze XR (saxagliptin/metformin HCl extended-release)** free to eligible patients facing financial hardship. It covers eligibility, application steps, and more to help you access this important diabetes medication without high costs. ## About Kombiglyze XR **Kombiglyze XR** is a prescription medication used to improve blood sugar control in adults with **type 2 diabetes**, when diet and exercise alone are not enough. It combines two active ingredients: **saxagliptin**, a DPP-4 inhibitor that helps the body release more insulin after meals, and **metformin HCl extended-release**, which reduces glucose production in the liver and improves insulin sensitivity. Taken once daily with evening meals, it helps lower A1C levels and reduce cardiovascular risks associated with diabetes. Always follow your doctor's instructions, as it may cause side effects like nausea, diarrhea, or low blood sugar when combined with other drugs. ## Who Qualifies for the Program? The BMSPAF program offers **Kombiglyze XR** at **no cost** to uninsured or underinsured U.S. residents (including Puerto Rico) who meet strict financial and medical criteria. Key requirements include: - Being **18 years or older**. - Residing in the **U.S. or Puerto Rico**. - Having **no prescription drug coverage** for any medications (details below). - Household income at or below **250% of the Federal Poverty Level (FPL)**. - A valid prescription from a licensed U.S. healthcare provider. Medicare Part D patients may qualify through **case-by-case appeals** if they demonstrate financial hardship and medical need, such as spending at least 3% of household income on out-of-pocket prescriptions. ## Income Eligibility Breakdown Eligibility is based on **total annual household income** (before taxes) compared to **250% of the FPL**. Income includes wages, Social Security, pensions, child support, and more. Provide proof like tax returns (Form 1040), SSA-1099, or non-filing verification (Form 4506-T). Here's a table with 2026 FPL guidelines (approximate; check current levels at apply.bmspaf.org or call 800-736-0003, as they update yearly): | Household Size | 100% FPL | 250% FPL (Eligibility Limit) | |---------------|----------|------------------------------| | 1 | $15,060 | **$37,650** | | 2 | $20,440 | **$51,100** | | 3 | $25,820 | **$64,550** | | 4 | $31,200 | **$78,000** | | +1 per person | +$5,380 | **+$13,450** | *Notes: Add $5,380 (100% FPL) per additional person and multiply by 2.5 for the limit. Alaskans and Hawaiians have higher thresholds. Zero income may still qualify with proof.* ## Insurance Requirements - **No prescription coverage** for **any medications** (private, Medicaid, VA, etc.). - List all insurance on the application. - **Medicare Part D**: Possible via appeal if you've spent significantly on copays (e.g., 3%+ of income) and show hardship. - Patients with coverage that excludes **Kombiglyze XR** or makes it unaffordable may qualify case-by-case. If insured, explore BMS Access Support first for copay help before BMSPAF. ## Step-by-Step Application Process BMSPAF offers **multiple application methods**: mail, fax, or download forms online. 1. **Get the form**: Visit bmspaf.org, call **800-736-0003** (Mon-Fri, 8am-8pm ET), or download from rxhope.com or prescriberpoint.com. 2. **Complete patient section**: Provide name, address, DOB, income details, household size, all medications/insurance, and sign. 3. **Doctor completes section**: Include prescription (attach separately; do **not** staple to form), diagnosis, treatment plan. 4. **Gather documents**: - **Proof of income** (tax return, pay stubs, benefit letters). - **Doctor-completed section**. - **Signed patient application**. 5. **Submit**: - **Mail**: Bristol-Myers Squibb PAF, P.O. Box 1058, Somerville, NJ 08876 or PO Box 220769, Charlotte, NC 28222-0769. - **Fax**: 800-736-1611 (no multiples). - Phone support for questions. **Tip**: Complete **everything**—missing info delays processing. ## Timeline and Delivery - **Processing**: Varies (days to weeks); complete apps reviewed quickly. You'll get mail notification. - **If approved**: **90-day supply** shipped **free to your doctor's office** (or home in some cases). Coverage up to **12 months**; Medicare patients reapply yearly. - **Reauthorization**: **Required** annually or for refills—resubmit form with updated income/proof. ## Alternatives if Denied or Ineligible - **BMS Access Support**: Copay cards, prior auth help (bmsaccesssupport.com). - **Other PAPs**: NeedyMeds, RxAssist, or PAN Foundation for diabetes meds. - **State programs**: Check your state's assistance. - **Generic options**: Metformin ER alone or saxagliptin alternatives (discuss with doctor). - **No biosimilars** for Kombiglyze XR currently. - **Appeal**: Call 800-736-0003 if denied—provide more financial proof. ## Important Disclaimer This guide is for informational purposes based on publicly available BMSPAF details as of 2026. Program rules, income limits, and availability can change without notice—verify with BMSPAF at 800-736-0003 or bmspaf.org. Not medical advice; consult your doctor. BMSPAF doesn't guarantee approval. Free meds up to 1 year; reapply to continue. Privacy: They collect income/insurance data for eligibility.

Program information last verified: March 30, 2026