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THE ORENCIA® (abatacept) COPAY PROGRAM™

A Copay Program for New and Existing ORENCIA Patients With Moderate to Severe Rheumatoid Arthritis (RA), covered by commercial insurance

Could ORENCIA® (abatacept) be right for you? THE ORENCIA® (abatacept) COPAY PROGRAM™ is a one-of-a-kind offer that makes it easier to experience ORENCIA, if you and your doctor decide it's right for your moderate to severe rheumatoid arthritis (RA).

More information button Get more information about ORENCIA. Click Here
ORENCIA is a prescription medicine that reduces signs and symptoms in adults with moderate to severe RA, including those who have not been helped enough by other medicines for RA, such as methotrexate, Enbrel®, Humira®, and Remicade®. It has been proven to:
• Relieve the pain, swelling, and fatigue of RA
• Slow the progression of joint damage
• Help improve physical and emotional health-related quality of life
Click here to request information about ORENCIA that's been tailored to your needs.
Indication and Important Safety Information

Indication and Usage

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.

Important Safety Information About ORENCIA® (abatacept)

Before you receive treatment with ORENCIA, a lyophilized powder for intravenous infusion, you should tell your doctor about all your medical conditions, including if you:

  • have any kind of infection even if it is small (such as an open cut or sore) or an infection that is in your whole body (such as the flu).
  • have an infection that will not go away or a history of infections that keep coming back.
  • 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 dry cough that doesn't go away, weight loss, fever, night sweats), call your doctor right away. Before you start ORENCIA, your doctor may examine you for TB or perform a skin test.
  • have or have had viral hepatitis. Before you use ORENCIA, your doctor may examine you for hepatitis.
  • have a history of chronic obstructive pulmonary (lung) disease (COPD).
  • are scheduled to have surgery.
  • are allergic to any of the following ingredients in ORENCIA: abatacept, maltose, monobasic sodium phosphate, or sodium chloride for administration.
  • recently received a vaccination or are scheduled for any vaccination.
  • 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 doctor may tell you to use a different way to monitor your blood sugar levels.
  • are pregnant, planning to become pregnant, or are thinking about becoming pregnant. It is not known if ORENCIA can harm your unborn baby.
  • are breast-feeding. You will need to decide to either breast-feed or receive treatment with ORENCIA, but not both.
  • take any other kinds of medicine, including prescription and nonprescription medicines, vitamins, and herbal supplements.
  • are taking other biologic medicines to treat RA such as: Enbrel® (etanercept),
    Humira® (adalimumab), Remicade® (infliximab), Kineret® (anakinra) or Rituxan® (rituximab). 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. Patients receiving ORENCIA have a higher chance of getting infections including pneumonia, and other infections caused by viruses, bacteria, or fungi. Call your doctor 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 on the day of treatment or the day after receiving ORENCIA. Tell your doctor or get emergency medical help right away if you have hives, swollen face, eyelids, lips, tongue, throat, 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.
  • 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, pneumonia, cough, or trouble breathing.

The more common side effects with ORENCIA are headache, upper respiratory tract infection, sore throat, and nausea.

Please read the Patient Information in the Full Prescribing Information. Top of Page ORENCIA (abatacept)
Orencia (abatacept)

Please fill out the following information. *Indicates required field

* Must be 18 years of age or older to register for information

ABOUT YOUR TREATMENT

ABOUT TREATMENT

*Have you been diagnosed with rheumatoid arthritis? *Has the patient been diagnosed with rheumatoid arthritis? *Has the patient been diagnosed with juvenile idiopathic arthritis? *Have you been diagnosed with juvenile idiopathic arthritis?

 Yes  No  Don't Know
 Yes  No  Don't Know

If so, what year was the child born?

How long ago were you diagnosed? How long ago was the patient diagnosed?

<1 Year 1-2 2-3 3-5 5-10 10+ Years

*How is your current medication(s) administered? *How is the patient's current medication administered?

 Infusion (IV)
 Injection (shot)
 Oral (pill)
 Not currently taking a medication
Which infusion medication(s) are you currently taking or have you recently been prescribed
for your rheumatoid arthritis? Which infusion medication(s) is the patient currently taking or has recently been prescribed
for his/her rheumatoid arthritis? Which infusion medication(s) is the patient currently taking or has recently been prescribed
for his/her JIA? Which infusion medication(s) are you currently taking or have you recently been prescribed
for your juvenile idiopathic arthritis?
 Methotrexate
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Orencia® (abatacept)
*What is/was the date of your first Orencia infusion? *What is/was the date of the patient's first Orencia infusion?
  >6 months 
 		   Within the past 6 months
 		   In the future 
 		   Not sure /
       Have not scheduled
*Select date:  
 Remicade® (infliximab)
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Rituxan® (rituximab)
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Actemra® (tocilizumab)
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Don't Know
Which injection medication(s) are you currently taking or have you recently been prescribed
for your rheumatoid arthritis? Which injection medication(s) is the patient currently taking or has recently been prescribed
for his/her rheumatoid arthritis? Which injection medication(s) is the patient currently taking or has recently been prescribed
for his/her JIA? Which injection medication(s) are you currently taking or have you recently been prescribed
for your juvenile idiopathic arthritis?
 Methotrexate
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Cimzia® (certolizumab pegol)
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Enbrel® (etanercept)
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Humira® (adalimumab)
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Kineret® (anakinra)
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Simponi™ (golimumab)
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Don't Know
Which oral medication(s) are you currently taking or have you recently been prescribed
for your rheumatoid arthritis? Which oral medication(s) is the patient currently taking or has recently been prescribed
for his/her rheumatoid arthritis? Which oral medication(s) is the patient currently taking or has recently been prescribed
for his/her JIA? Which oral medication(s) are you currently taking or have you recently been prescribed
for your juvenile idiopathic arthritis?
 Methotrexate
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Arava® (leflunomide)
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Azulfidine® (sulfasalazine)
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Plaquenil® (hydroxychloroquine)
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Ridaura® (auranofin)
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Over-the-counter nonprescription medication
For how many years have you been taking this medication? For how many years has the patient been taking this medication?
<1 Year 1-2 2-3 3-5 5-10 10+ Years
 Other
 Don't Know
What type of physician are you seeing? What type of physician is the patient seeing?
 
Name of physician:   
*Select 3 everyday tasks you find challenging: *Select 3 everyday tasks the patient finds challenging:
 Opening a jar  Turning a key  Bending down  Fastening a button
 Brushing teeth  Using a knife  Climbing stairs  Getting out of bed
 
 Lifting  Shaving  I do not find any of these
        tasks challenging
*How satisfied are you with your current RA treatment? *How satisfied is the patient with his/her current RA treatment? *How satisfied are you with your current JIA treatment? *How satisfied is the patient with his/her current JIA treatment?
NOT AT ALL
SATISFIED		 EXTREMELY
SATISFIED
1 2 3 4 5 6 7 8 9 10

*Has your doctor recently discussed changing your RA treatment? *Has the patient's doctor recently discussed changing his/her RA treatment? *Has your doctor recently discussed changing your JIA treatment? *Has the patient's doctor recently discussed changing his/her JIA treatment?

 Yes  No  
Which of the following medication(s) are you and your doctor considering? Which of the following medication(s) is the patient and his/her doctor considering?
 Actemra®(tocilizumab)  Orencia®(abatacept)
 Cimzia®(certolizumab pegol)  Remicade®(infliximab)
 Enbrel®(etanercept)  Rituxan®(rituximab)
 Humira®(adalimumab)  Simponi®(golimumab)
 Kineret®(anakinra)  None at this time
When is your next scheduled doctor appointment? When is the patient's next scheduled doctor appointment?
 Within the next week
 Within the next 2 weeks
 Within the next month
 Within the next 2 months
 Within the next 3-6 months
Which of the following medication(s) are you and your doctor considering? Which of the following medication(s) is the patient and his/her doctor considering?
 Methotrexate  Azulfidine®(sulfasalazine)
 Humira®(adalimumab)  Enbrel®(etanercept)
   Orencia®(abatacept)
When is your next scheduled doctor appointment? When is the patient's next scheduled doctor appointment?
 Within the next week
 Within the next 2 weeks
 Within the next month
 Within the next 2 months
 Within the next 4-6 months

*Please indicate how important it is to you that a rheumatoid arthritis medication improves
health-related quality of life (allows you to do the things you need and want to do).
Please choose any number from "1" to "5." *Please indicate how important it is to the patient that a rheumatoid arthritis medication improves
health-related quality of life (allows the patient to do the things he/she needs and wants to do).
Please choose any number from "1" to "5." *Please indicate how important it is to the patient that a juvenile idiopathic arthritis medication improves
health-related quality of life (allows the patient to do the things he/she needs and wants to do).
Please choose any number from "1" to "5." *Please indicate how important it is to you that a juvenile idiopathic arthritis medication improves
health-related quality of life (allows you to do the things you need and want to do).
Please choose any number from "1" to "5."

 1  2  3  4  5



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Eligibility, Terms, and Conditions
  • This program covers the drug cost of the ORENCIA copay only, not the cost of the infusion.
  • Eligible patients must be appropriate patients for the treatment of moderate to severe RA or moderate to severe active polyarticular JIA with ORENCIA.
  • Eligible patients must have commercial insurance that pays for ORENCIA.
  • Eligible patients must not have coverage for ORENCIA through Medicare, Medicaid, TRICARE, VA, or other federally funded healthcare programs.
  • All coverage requirements mandated by the insurance company of the eligible patient must be satisfied in order for the program to take effect.
  • 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.
  • Proof required for payment must be a valid Explanation of Benefits (EOB) with ORENCIA J Code specific information.
  • Explanation of Benefits (EOB) must be submitted regardless of assigned J Code value.
  • Explanation of Benefits (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 $5,000 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 benefi ts will be issued to the participating patient by check.
  • For Specialty Pharmacies, the program card serves as payment mechanism at the specialty 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 may not be combined with any other coupon, discount, prescription savings card, free trial, or other offer for ORENCIA.
  • This offer is valid in the United States, excluding Massachusetts or where it is prohibited by law.
  • This is a limited time offer. BMS reserves the right to rescind, revoke, amend, or terminate this offer, or the program in its entirety, at any time.