Acceptance of this offer confirms that this offer is consistent with patient’s insurance.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.Program payments are for the benefit of the patient only.The Program will not cover the cost of any dosing procedure, any other healthcare provider service, supply charges, or other treatment costs. Program benefits are limited to the co-pay costs for ORENCIA that the patient receives as an outpatient.The Program may apply to out-of-pocket expenses that occurred within 180 days prior to the date of enrollment. The enrollment period is 1 calendar year. 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. 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).Upon expiration, eligible patients may re-enroll using the same card. The Card expires at the end of the calendar year following activation. The Card must be activated before use and includes 13 uses per calendar year.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.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. 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. Some prescription drug plans have established programs referred to as ‘co-pay maximizer’ programs.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.Patients or their guardian must be 18 years of age or older.
Patients must be treated with ORENCIA for an FDA-approved indication.Cash-paying patients are not eligible for co-pay assistance.Patients who move from commercial to federal health insurance will no longer be eligible. 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.Co-pay assistance is not available if patient out-of-pocket expenses are $5 or less.
#Cosentyx copay card number full#
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