Hepatosplenic T-cell lymphoma, a rare form of fatal lymphoma, has occurred mostly in teenage or young adult males with Crohn’s disease or ulcerative colitis who were taking infliximab products and azathioprine or 6-mercaptopurine. Unusual cancers have been reported in children and teenage patients taking tumor necrosis factor (TNF)-blocker medicines. Your doctor should monitor you closely for signs and symptoms of TB during treatment with RENFLEXIS. Some of these infections have been fatal. Some patients, especially those 65 years and older, have had serious infections caused by viruses, fungi, or bacteria that have spread throughout the body, including tuberculosis (TB) and histoplasmosis. RENFLEXIS can cause serious side effects such as lowering your ability to fight infections. reserves the right to rescind, revoke, or amend the program and discontinue support at any time without notice.Only your doctor can recommend a course of treatment after checking your health condition. Program may not be combined with any third-party rebate, coupon, or offer. Valid only in the United States and Puerto Rico. Patient is responsible for complying with any applicable limitations and requirements of their health plan related to the use of the program. Patient may not seek reimbursement for the value received from this program from other parties, including any health insurance program or plan. Program is not valid where prohibited by law. The value of the program is exclusively for the benefit of patients and is not intended to be credited toward patient out-of-pocket obligations and maximums, including applicable co-payments, co-insurance and deductibles. Program is not valid (i) under Medicare, Medicaid, TRICARE, VA, DoD or any other federal or state health care program, (ii) where patient is not using insurance coverage at all, or (iii) where the patients' insurance plan reimbursees the entire cost of the drug. Patient is responsible for any costs once the dollar limit is reached during the program calendar year. The program includes the copay card, payment card (if applicable) with a combined annual limit of $13,000. Valid only for those with private insurance. I understand I may request a signed copy of this Authorization.* Cancellation of this Authorization will end further uses and disclosures of my or my child's Information and my or my child's participation in the Program but will not affect any uses or disclosure of my or my child's Information made by my or my child's health care providers and staff, pharmacies, and health insurers based on this Authorization before receipt of the cancellation. I may change my mind and cancel this Authorization at any time by calling 1-86 or by notifying Sobi in writing at KINERET ON TRACK, PO Box 29076, Phoenix, AZ 85038-9076. I understand that this Authorization expires ten years from the date signed below, or as otherwise required by state or local law, unless and until I cancel (take back) this Authorization before then. However, if I do not sign this Authorization, I understand I or my child will not be able to participate in the Program. A decision by me not to sign this Authorization will not affect my or my child's ability to obtain medical treatment from healthcare providers, eligibility for health insurance benefits, or access to Sobi medications. I understand that I do not have to sign this Authorization. I understand and agree that the pharmacy that dispenses KINERET may receive payment from Sobi in exchange for disclosing my or my child's Information to Sobi and providing Program services. However, I also understand that Sobi will protect my or my child's Information by using and disclosing it only for the purposes allowed by me in this Authorization or as otherwise required by law.

Once my or my child's Information has been disclosed to Sobi, I understand that federal privacy laws may no longer protect it from further disclosure. I authorize my or my child's healthcare providers and staff, pharmacies, and health insurers to use and to disclose to Sobi, Inc., and its affiliates, business partners, vendors, and other agents (collectively, 'Sobi') health information, including information related to me or my child's medical condition and treatment, health insurance and coverage claims, and prescription (including fill/refill information) for KINERET ('Information') to (1) enroll me or my child in and provide services under the KINERET ON TRACK ™ patient support program (the 'Program') (2) obtain information on my or my child's insurance coverage (3) coordinate prescription fulfillment as indicated by my or my child's physician (4) provide me with adherence reminders and support and (5) contact me to conduct market research and to arrange for my receipt of educational, promotional, and/or marketing materials about Sobi support programs or Sobi products.

Orencia copay card program