TERMS AND CONDITIONS FOR THE ORENCIA^® (abatacept) COPAY PROGRAM FOR SELF-INJECTION

Eligibility, Terms, and Conditions

• Eligible patients must be appropriate adult patients (18 years of age or older) for the treatment of moderate to severely active RA.
• Eligible patients must have commercial insurance that pays for ORENCIA^® (abatacept). 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.
• The ORENCIA Copay 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.
• Copay Assistance Card benefit includes 12 uses per calendar year, up to a maximum benefit of $8,000.
• 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.
• Other restrictions and exclusions may apply; please refer to THE ORENCIA^® (abatacept) COPAY PROGRAM brochure for self-injection for Terms and Conditions.

REIMBURSEMENT OPTION

If your pharmacy does not accept your ORENCIA^® (abatacept) Copay Assistance Card, you can still receive the same benefits using the provided rebate form.

• Complete the reimbursement form provided in your Copay Assistance Card package.
• Enclose the original pharmacy receipt. (A valid receipt should include your name, the name of the medicine you purchased, the date, and the amount you paid.) Be sure to circle:
  • ORENCIA^® (abatacept)
  • date of purchase
  • amount you paid
  • medication quantity
• Include a photocopy of your Copay Assistance Card.
• Enclose the original receipt and photocopy of your Copay Assistance Card in the pre-paid reimbursement form, seal all 3 sides and place in the mail.

ORENCIA^® (abatacept) FOR INITIAL IV INFUSION REIMBURSEMENT OPTION

Eligible patients can also get help with their out-of-pocket drug costs for the initial intravenous dose of ORENCIA^® (abatacept) for infusion.

• The purpose of this program is to assist patients with out-of-pocket drug cost for the initial infusion of ORENCIA^® (abatacept). Only the drug cost of the ORENCIA copay is eligible for reimbursement, NOT the cost of the infusion.
• Eligible patients must be appropriate adult patients for the treatment of moderate to severely active rheumatoid arthritis.
• 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.
• Federally-funded commercial insurance plans are NOT eligible.
• Patients who move from commercial to federally-funded insurance will no longer be eligible for the program.
• Program benefit is limited to a single date of service.
• 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.
• 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.
• Other restrictions and exclusions may apply; please refer to THE ORENCIA^® (abatacept) COPAY PROGRAM brochure for self-injection for Terms and Conditions.