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TERMS AND CONDITIONS FOR THE ORENCIA® (abatacept) COPAY PROGRAM FOR IV INFUSION

Eligibility, Terms, and Conditions

  • The Copay card is not an insurance card. This program assists patients with their out-of-pocket drug cost of ORENCIA only, not the cost of the infusion.
  • Eligible patients must be appropriate patients for the treatment of moderate to severely active RA or moderate to severely active polyarticular JIA with ORENCIA.
  • Eligible patients must have commercial insurance that pays for ORENCIA. Savings are not applicable to out-of-pocket expenses of $5 or less.
  • 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.
  • Patients enrolled in Medicare, Medicare Part D, Medicare Advantage, Medicaid, Tricare, Veterans Affairs (VA), Department of Defense (DoD), other state- or federally-funded programs, or where otherwise prohibited by law are not eligible for this program.
  • Patients who move from commercial to federally-funded insurance will no longer be eligible for the program.
  • Federally-funded commercial insurance plans are NOT eligible.
  • All coverage requirements mandated by the insurance company of the eligible patient must be satisfied in order for the program to take effect.
  • Proof required for reimbursement must be a valid Explanation of Benefits (EOB) with ORENCIA J Code specific information.
  • EOB must be submitted regardless of assigned J Code value.
  • EOB must be submitted within 90 days post-infusion to receive benefit.
  • First ORENCIA infusion must take place within 60 days of enrollment in the program.
  • Enrollment Period is 12 months from date of enrollment.
  • Program has a payment cap of $8,000 for the 12-month term of enrollment.
  • Benefits may apply to one retroactive infusion that occurred within 45 days prior to the date of enrollment, only for patients who have had their eligibility confirmed by the program.
  • Active copay cards are for use at the patient’s participating healthcare provider office where MasterCard® debit cards are accepted.
  • Healthcare providers who do not accept electronic transactions will be identified on enrollment form and program benefits will be issued to the participating patient by check.
  • When the prescription for ORENCIA is filled directly by a pharmacy, the program card serves as payment mechanism at the pharmacy only.
  • For Hospital Outpatient Departments or Alternate Sites of Care, each facility serves as an infusion site-of-care only. Patient is responsible for site of care financial obligation and will receive program benefits by check.
  • This offer is valid in the United States, excluding where it is prohibited by law.
  • BMS reserves the right to modify or terminate this offer, or the program in its entirety, at any time.
  • This is a limited time offer. Other restrictions and exclusions may apply; please refer to THE ORENCIA® (abatacept) COPAY PROGRAM brochure for infusion for more information.
 

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

Eligibility, Terms, and Conditions

  • Eligible patients must be appropriate adult patients (18 years of age or older), who have been prescribed ORENCIA for the treatment of moderate to severely active RA.
  • Eligible patients must have commercial insurance that pays for ORENCIA and the insurance 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.
  • 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.
  • Patients enrolled in Medicare, Medicare Part D, Medicare Advantage, Medicaid, Tricare, Veterans Affairs (VA), Department of Defense (DoD), other state or federal healthcare programs, or where otherwise prohibited by law, are not eligible for this program.
  • Patients who move from commercial to federal health insurance will no longer be eligible for the program.
  • Federally-funded commercial insurance plans are NOT eligible: however, patients who purchased their prescription insurance through a Health Insurance Exchange (also known as a Health Insurance Marketplace or Small Business Health Options Program (SHOP) Marketplace) are currently eligible.
  • The ORENCIA Co-pay Assistance Card is not insurance. The 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 $10,000.
  • This offer is valid only in the United States and Puerto Rico, excluding where it is prohibited by law.
  • The Co-pay Card is not transferable and 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.
  • BMS reserves the right to modify or terminate this offer, or the program in its entirety, at any time.

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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SELECTED IMPORTANT SAFETY INFORMATION

ORENCIA can cause serious side effects including:

Serious infections. ORENCIA can make you more likely to get infections or make the infection that you have get worse. Some patients have died from these infections. Call your healthcare provider immediately if you feel sick or get any of the following signs of infection: fever; feel very tired; cough; feel flu-like; or warm, red or painful skin.

More Important Safety Information

Important Safety Information and Indication/Usage

Important Safety Information

More Important Safety Information

Inform your healthcare provider of the following, before you receive treatment with ORENCIA® (abatacept):

Infections: If you have any kind of infection, even if it is small (such as an open cut or sore), an infection that is in your whole body (such as the flu), an infection that will not go away, or a history of infections that keep coming back. ORENCIA may make your immune system less able to fight infections, so you may be more likely to get infections or any infection you have may get worse.

Tuberculosis: If you have had tuberculosis (TB), a positive skin test for TB, or if you recently have been in close contact with someone who has had TB. If you get any of the symptoms of TB (a cough that does not go away, weight loss, fever, night sweats), call your healthcare provider right away. Before you start ORENCIA, your healthcare provider may examine you for TB or perform a skin test.

If you have or have had Viral Hepatitis. Before you use ORENCIA, your healthcare provider may examine you for hepatitis.

If you have a history of Chronic Obstructive Pulmonary (lung) Disease (COPD).

If you are scheduled to have Surgery.

Allergies to the Ingredients of ORENCIA: The ingredients of intravenous (IV) ORENCIA are: abatacept, maltose, monobasic sodium phosphate, and sodium chloride for administration. The ingredients of subcutaneous (SC) ORENCIA are: abatacept, sucrose, poloxamer 188, monobasic sodium phosphate monohydrate, dibasic sodium phosphate anhydrous, and water for injection.

Vaccinations: If you have recently received a vaccination or are scheduled for any vaccination. If you are receiving ORENCIA, and for 3 months after you stop receiving ORENCIA, you should not take live vaccines.

Diabetes: If you have diabetes and use a blood glucose monitor to check your sugar levels. The infusion of ORENCIA contains maltose, a sugar that can give falsely high blood glucose readings with some monitors on the day you receive your infusion. Your healthcare provider may tell you to use a different way to monitor your blood sugar levels. ORENCIA for SC injection does not contain maltose; therefore, you do not need to change the way you monitor your blood sugar if you are taking ORENCIA subcutaneously.

Pregnancy: If you are pregnant, planning to become pregnant, or are thinking about becoming pregnant. It is not known if ORENCIA can harm your unborn baby.

Breastfeeding: You will need to decide to either breastfeed or receive treatment with ORENCIA, but not both.

If you Take Any Other Kinds of Medicine, including prescription and nonprescription medicines, vitamins, and herbal supplements.

If you are Taking Other Biologic Medicines to Treat RA or JIA such as: Enbrel® (etanercept), Humira® (adalimumab), Remicade® (infliximab), Kineret® (anakinra), Rituxan® (rituximab), Simponi® (golimumab), Cimzia® (certolizumab pegol), or Actemra® (tocilizumab). You may have a higher chance of getting a serious infection if you take ORENCIA with other biologic medicines.

Possible Side Effects of ORENCIA® (abatacept)

ORENCIA can cause serious side effects including:

  • Serious infections. ORENCIA can make you more likely to get infections or make the infection that you have get worse. Some patients have died from these infections. Call your healthcare provider immediately if you feel sick or get any of the following signs of infection: fever; feel very tired; cough; feel flu-like; or warm, red or painful skin.
  • Allergic reactions. Allergic reactions can happen to people who use ORENCIA. Call your healthcare provider or get emergency medical help right away if you have any symptoms of an allergic reaction, which may include hives; swollen face, eyelids, lips, or tongue; or trouble breathing.
  • Hepatitis B infection. If you are a carrier of the hepatitis B virus (a virus that affects the liver), the virus can become active while you use ORENCIA. Your healthcare provider may do a blood test before you start or while using ORENCIA.
  • Vaccinations. You should not receive ORENCIA with certain types of vaccines. ORENCIA may cause some vaccinations to be less effective.
  • Respiratory problems in patients with COPD. You may get certain respiratory problems more often if you receive ORENCIA and have COPD, including: worsened COPD, cough, or trouble breathing.
  • Cancer (malignancies). Certain kinds of cancer have been reported in patients receiving ORENCIA. It is not known if ORENCIA increases your chance of getting certain kinds of cancer.

Common side effects with ORENCIA are headache, upper respiratory tract infection, sore throat, and nausea. Other side effects in children and adolescents may include diarrhea, cough, fever, and abdominal pain.

Note concerning ORENCIA SC: It is not known if ORENCIA for SC injection is safe and effective in children under 18 years of age.

Indication/Usage

Adult Rheumatoid Arthritis (RA): ORENCIA® (abatacept) is a prescription medicine that reduces signs and symptoms in adults with moderate to severe rheumatoid arthritis (RA), including those who have not been helped enough by other medicines for RA. ORENCIA may prevent further damage to your bones and joints and may help your ability to perform daily activities. In adults, ORENCIA may be used alone or with other RA treatments other than tumor necrosis factor (TNF) antagonists.

Juvenile Idiopathic Arthritis (JIA): ORENCIA reduces signs and symptoms in children and adolescents 6 years of age and older with moderate to severe polyarticular juvenile idiopathic arthritis (JIA). ORENCIA may be used alone or with methotrexate (MTX).

Please click here to read the Patient Information in the Full Prescribing Information.