Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 4.
Scroll down to see them all.
Updated November 13, 2014
 

Orencia

Bristol-Myers Squibb Patient Assistance Foundation

This program provides brand name medications at no or low cost.

Provided by: Bristol-Myers Squibb Company

PO Box 220769
Charlotte, NC 28222-0769

TEL: 800-736-0003


ALT PHONE:
FAX: 800-736-1611
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Patient Assistance Applications

Bristol-Myers Squibb Patient Assistance Foundation Application

 

Medications

  • Orencia Infusion 250mg (abatacept)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage
Those with Part D Eligible? Considered on exception basis
Income At or below 250% of FPL
Diagnosis/Medical Criteria Medication must be for outpatient use only
US Residency Required? Must reside in the US, Puerto Rico or the USVI
   

Application

Obtaining Call or download
Receiving Faxed
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within a week
   

Medication

Amount/Supply Varies
Sent To Doctor's office
Delivery Time Within 5-7 business days
Refill Process Doctor/Doctor's office must contact company
Limit None
Re-application New application yearly
   

Additional Information

Contact program for Spanish application.


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 4.
Scroll down to see them all.
Updated October 23, 2014
 

Orencia

Diplomat's Co-Pay Assistance Navigator Program

This is a copay assistance program.

Provided by: Diplomat Specialty Pharmacy

ATTN: FUNDING ASSISTANCE
4100 S Saginaw Street
Flint, MI 48507

TEL: 877-977-9118 ext. 89864


ALT PHONE:
FAX: 810-282-0176
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Diplomat Request of Financial Assistance Form

 

Medications

  • Orencia Injection 250mg/mL (abatacept)
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Yes
Income Determined case by case
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Yes
   

Application

Obtaining Call or complete online
Receiving Faxed, mailed or complete online
Returning Fax or mail
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section, sign and provide annual income information. Proof of income may be request by program at any time
Decision Communicated Patient and/or Doctor are notified
Decision Timeframe Within 1-2 business days
   

Medication

Amount/Supply Amount requested is sent
Sent To Patient's home
Delivery Time Once approved; within 2 business days
Refill Process Company contacts patient to arrange
Limit Varies per medication
Re-application Determined case by case
   

Additional Information

Diplomat Specialty Pharmacy is a full service pharmacy that can help patients seek funding assistance for the copay portion of their required medications. Applications can be completed online or Prescription, Demographics and Proof of Income may be faxed to 810-282-0176 Attn: Dorrie



Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 4.
Scroll down to see them all.
Updated October 17, 2014
 

Orencia

Patient Access Network Foundation (PAN)

This is a copay assistance program.

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


ALT PHONE:
FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Patient Assistance Applications

PAN Brochure

PAN Eligibility Criteria and Benefit Cap Information

PAN Proof of Expenditure Form

 

Medications

  • Orencia Injection 250mg/mL (abatacept)
 

Eligibility Requirements   

Insurance Status Must have insurance
Those with Part D Eligible? Determined case by case
Income At or below 500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Fax, mail or submit online
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section and sign
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 4 of 4. Updated November 12, 2014
 

Orencia

Orencia Co-Pay Program

This is a copay assistance program.

Provided by: Bristol-Myers Squibb Company

BMS Access Support
PO Box 220745
Charlotte, NC 28222-1509

TEL: 1-800-861-0048


ALT PHONE: 1-800-673-6242
FAX:
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Orencia Co-Pay Program Enrollment Form

 

Medications

  • Orencia Vial; IV 250mg (abatacept)
 

Eligibility Requirements   

Insurance Status Must be commercially insured
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Must be 18 yr old or older
US Residency Required? Must reside in the US
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax
Doctor's Action Complete section, sign, attach prescription
Applicant's Action Complete section, sign, attach proof of income
Decision Communicated Not applicable
Decision Timeframe Not applicable
   

Medication

Amount/Supply Not applicable
Sent To Not applicable
Delivery Time Not applicable
Refill Process Good for one year
Limit Maximum of 12 times in one year
Re-application Must re-enroll at end of calendar year
   

Additional Information

Eligible patients may receive up to $8,000 in copay assistance yearly.