TERMS AND CONDITIONS FOR THE ORENCIA® (abatacept) CO-PAY PROGRAM FOR SUBCUTANEOUS USE

  • Patients must have commercial insurance that pays for ORENCIA but does not cover the full cost; that is, you must have a co-pay obligation. Co-pay assistance is not available if your out-of-pocket expenses are $5 or less.
  • Patients who have prescription insurance coverage through a state or federal healthcare program, including Medicare, Medicare Part D, Medicare Advantage, Medicaid, Tricare, Veterans Affairs (VA), or Department of Defense (DoD) programs are not eligible for this program; patients who move from commercial to federal health insurance will no longer be eligible.
  • Patients who purchased their prescription drug insurance through a Health Insurance Exchange (also known as a Health Insurance Marketplace or Small Business Health Options Program (SHOP) Marketplace) are currently eligible.
  • Patients or their guardian must be 18 years of age or older.
  • The ORENCIA Co-pay Assistance Card must be presented at the pharmacy, along with a valid prescription for ORENCIA for self-injection, at the time of purchase.
  • Patient pays $5 out-of-pocket drug cost per one-month supply with no monthly benefit limit.
  • The Co-pay Assistance Card benefit includes 12 uses per calendar year, up to a maximum benefit of $15,000.
  • The Co-pay Card must be activated before use and expires on December 31, 2019.
  • Program payments are for the benefit of the patient only.
  • Patients, guardians, pharmacists, and healthcare 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.
  • Offer valid only in the United States and Puerto Rico; void where prohibited by law, taxed or restricted.
  • Absent a change in Massachusetts law, effective July 1, 2019, Massachusetts residents will no longer be able to participate in this Program.
  • The Co-pay Card is not transferable and is limited to 1 per patient. This offer may not be combined with any other rebate/coupon, free trial or similar offer.
  • The Co-pay Card may not be sold, purchased, traded or counterfeited. Reproductions of the Co-pay Card are void.
  • No membership fees.
  • This offer is not conditioned on any past, present or future purchase, including refills.
  • The ORENCIA Co-pay Assistance Card is not insurance.
  • BMS reserves the right to modify or terminate this offer at any time without notice.

BY USING THIS CARD, THE PATIENT AND THE PATIENT'S PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE TERMS AND CONDITIONS.

Other restrictions and exclusions may apply; please refer to The ORENCIA® Co-Pay Program brochure for self-injection.

  • Check your insurance policy. Do not participate in this program if it is not consistent with the terms of your insurance policy, including if your insurance policy prohibits the use of these types of programs or if enrolling in this program would violate any of your policy's terms.
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ORENCIA is a registered trademark, and BMS Access Support and THE ORENCIA® (abatacept)
CO-PAY PROGRAM are trademarks of the Bristol-Myers Squibb Company
  
427US1801108-02-01 Aug/18