PRACTICE RESOURCES

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Program Overview Brochure

This brochure provides an overview of the support services provided by CIMERLI Solutions. There is information regarding the co-pay savings program, the patient assistance program, the field reimbursement managers as well as the billing and reimbursement support available.

Enrollment Form

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This form is the first step in enrollment into the Coherus SolutionsTM Program. Please complete this form if you are interested in benefit verification, appeals support, or the co-pay savings program.

PAP Enrollment Form

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This form should be used to enroll your patient into the patient assistance program.

Patient Consent

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This form may be used to obtain patient consent to disclose personal information in order to enroll into patient access programs.

Sample Coding Sheet (CMS 1450 form for Hospital Inpatient Claims)

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The sample claim forms provide an example of how a claim form may look when billing for CIMERLI. The UB-04 (CMS-1450) form should be used in the hospital outpatient site of care.

Sample Coding Sheet (CMS 1500 form for Outpatient Claims)

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The sample claim forms provide an example of how a claim form may look when billing for CIMERLI. The CMS-1500 should be used in the physician office or clinic.

Coding Reference Guide

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This coding guide provides overview of the billing codes associated with CIMERLI that may help you submit health insurance claims. This coding guide does not guarantee payment for CIMERLI. Please check with the payer to confirm the appropriate codes and any treatment approval requirements.

Product Fact Sheet

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This fact sheet provides a snapshot of important information related to CIMERLI including ordering and package information and coding and billing information.

Letter of Medical Necessity

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Prior to utilizing CIMERLI, the payer may require a prior authorization or a letter of medical necessity. This is a sample letter of medical necessity that may be used as a guide.

Letter of Appeals

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The letter of medical appeal may be helpful if you have received a denial from your patient's health insurance. Please review to determine what information should be included in an appeal.

Product Replacement Request Form

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Product Replacement Guidelines

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Patient Assistance Refill Request Form

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Virtual Debit Card Fax Request

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Have questions?

For questions regarding CIMERLI™ resources, call CIMERLI Solutions™ at 1-844-483-3692.

Terms and Conditions

Coherus’ Drug Copay Program and Administration Copay Program are different programs with unique eligibility for each. Patients must enroll separately as needed. To receive co-pay assistance for administration co-pay costs, the provider, patient, or caregiver must enroll eligible individual within 180 days after the date of service for which the subsidy is sought.

Participating patients, pharmacies, physician offices and hospitals may use Coherus’ patient services web portal or send completed enrollment forms to 1-877-226-6370 to enroll patients. Under the program, if a patient incurs a co-pay obligation for the administration of CIMERLI, and meets all eligibility requirements, Coherus shall subsidize the cost of administration up-to $1000 per calendar year. The program benefit will reset every January 1st. Re-enrollment in the program is required at regular intervals. Patients may participate in the program as long as patient re-enrolls as required by Coherus BioSciences and continues to meet all of the program’s eligibility requirements during participation in the program.. After reaching the maximum program benefit, the patient will be responsible for all remaining out-of-pocket expenses. The amount of the program’s benefits cannot exceed the patient’s out-of-pocket expenses for the cost of the drug or administration fees associated with CIMERLI.

The program is not valid if the costs are eligible to be reimbursed in their entirety by private insurance plans or other programs. The program is not valid for patients receiving assistance from any other third party, including charitable organizations, if assistance is for the same expenses covered by the programs. The administration assistance cannot be combined with any other rebate, free trial or similar offer for the medication or administration of the product unless otherwise permitted by Coherus. The program is not health insurance or a benefit plan.

All participants are responsible for reporting the receipt of all program benefits as required by any insurer or by law. The programs are only valid in the United States and U.S. Territories and otherwise void where prohibited by law, including in Minnesota, Rhode Island. *In Massachusetts special conditions apply. The injection administration copay may only be paid directly to the patient. Additional information may be required to facilitate payment directly to the patient. Program benefits may not be sold, purchased, traded or offered for sale.

The programs do not obligate use of any specific product or provider. Healthcare providers may not advertise or otherwise use the programs as a means of promoting their services or Coherus products to patients. Coherus reserves the right to rescind, revoke or amend the program without notice at any time.

Program Overview Brochure

Enrollment Form

PAP Enrollment Form

Patient Consent

Sample Coding Sheet (CMS 1450 form for Hospital Inpatient Claims)

Sample Coding Sheet (CMS 1500 form for Outpatient Claims)

Coding Reference Guide

Product Fact Sheet

Letter of Medical Necessity

Letter of Appeals

Product Replacement Request Form

Product Replacement Guidelines

Patient Assistance Refill Request Form

Virtual Debit Card Fax Request

Have questions?

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