LOQTORZI has a product-specific
J-Code: J3263

LOQTORZI CO-PAY SAVINGS SUPPORT PROGRAM TERMS AND CONDITIONS

To receive co-pay assistance for drug 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 fax completed enrollment forms to 1-877-226-6370 to enroll patients.

Under the LOQTORZI Co-Pay Savings Program, if a patient incurs a co-pay obligation for the cost of LOQTORZI, and meets all eligibility requirements, Coherus may provide co-pay assistance for up to $30,000 per calendar year.

The program benefits will reset every January 1st. Re-enrollment in the program is required at regular intervals. Patients may participate in the program as long as the patient re-enrolls as required by Coherus BioSciences and continues to meet all of the eligibility requirements for the program during participation in the program. After reaching the maximum benefit for either program, 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 LOQTORZI.

Patients must have commercial health insurance. Patients with any federal, state or government-funded healthcare coverage such as Medicare, Medicare Advantage, Medicare Part D, Veterans Affairs, Depart of Defense or Tricare are not eligible for the program.

The program is not available if the costs are eligible to be reimbursed in their entirety by private insurance plans or other programs. The program is not available for patients receiving assistance from any other third party, including charitable organizations, if assistance is for the same expenses covered by the program. This 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 program is only valid in the United States and US Territories and otherwise void where prohibited by law. Program benefits may not be sold, purchased, traded or offered for sale.

The program does 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.