1-800-ORENCIA- Patients must have commercial insurance that pays for ORENCIA but does not cover the full cost. Co-pay assistance is not available if patient
out-of-pocket expenses are $5 or less. - Patients who have insurance coverage through a state or federal healthcare program, including Medicare, Medicaid, Medigap, CHAMPUS, Tricare, Veterans Affairs (VA), or Department of Defense (DoD), are not eligible. Patients who move from commercial to federal health insurance will no longer be eligible.
- Cash-paying patients are not eligible for co-pay assistance.
- Patients must be treated with ORENCIA for an FDA-approved indication.
- Patients or their guardian must be 18 years of age or older.
- Eligible patients with an activated co-pay card and a valid prescription may pay as little as $5 per 30-day supply; monthly, annual, and/or per-claim maximum program benefits may apply and vary from patient to patient, depending on the terms of a patient’s prescription drug plan and to ensure that the funds are used for the benefit of the patient, based on factors determined solely by Bristol-Myers Squibb.
- Some prescription drug plans have established programs referred to as ‘co-pay maximizer’ programs. A co-pay maximizer program is one in which the amount of the patient’s out-of-pocket costs is adjusted to reflect the availability of support offered by a co-pay support program. Patients enrolled in co-pay maximizer programs may receive program benefits that vary over time to ensure the program funds are used for the benefit of the patient.
- For ORENCIA subcutaneous self-injection, the Co-pay Assistance Card must be presented at the pharmacy, along with a valid prescription for ORENCIA, at the time of purchase.
- The Card must be activated before use and includes 13 uses per calendar year. Patients will be evaluated for ongoing eligibility to continue enrollment in the program. In the event patients experience a change in insurance coverage or Bristol Myers Squibb makes changes to the copay assistance program, patients may be required to re-enroll into the program and provide updated insurance information to determine eligibility.
- For ORENCIA IV infusion, in order to receive Program benefits, the patient or provider must submit an Explanation of Benefits (EOB) form or a Remittance Advice (RA). The submitted form must include the name of the insurer, plan information, show that ORENCIA IV was the medication given, and be submitted within 180 days of the date of the EOB. The enrollment period is 1 calendar year. The Program may apply to out-of-pocket expenses that occurred within 180 days prior to the date of enrollment.
- Program benefits are limited to the co-pay costs for ORENCIA that the patient receives as an outpatient. The Program will not cover the cost of any dosing procedure, any other healthcare provider service, supply charges, or other treatment costs.
- Program payments are for the benefit of the patient only.
- Patients, guardians, pharmacists, and healthcare providers may not seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this Program.
- Acceptance of this offer confirms that this offer is consistent with patient’s insurance. Patients, pharmacists, and healthcare providers must report the receipt of co-pay assistance benefits if required by the patient’s insurance provider.
- Offer valid only in the United States and Puerto Rico; void where prohibited by law, taxed, or restricted.
- Program benefits are nontransferable. This offer may not be combined with any other rebate/coupon, free trial, or similar offer.
- Co-pay cards are limited to 1 per patient and may not be sold, purchased, traded, or counterfeited.
- No membership fees.
- Program offer is not conditioned on any past, present, or future purchase, including additional doses or refills.
- The Program is not insurance.
- Bristol Myers Squibb reserves the right to rescind, revoke, or amend this offer at any time without notice. Other restrictions may apply.