PRACTICE RESOURCES

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Practice and Patients

Program Overview Brochure

This brochure provides an overview of the support services provided by LOQTORZI 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

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, the co-pay savings program, or the patient assistance program (PAP).

Patient Consent

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

Sample Coding Claim Form (CMS-1450)

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

Sample Coding Claim Form (CMS 1500)

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

Coding Flashcard

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

Product Fact Sheet

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

Letter of Medical Necessity

Prior to utilizing LOQTORZI, 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

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.

Alternative Funding Resources

This guide provides an overview of foundations and other related organizations offering various types of information and support.

Have questions?

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

LOQTORZI CO-PAY SAVINGS SUPPORT PROGRAM TERMS AND CONDITIONS

If your patient would like to enroll in the co-pay program to receive co-pay assistance, you can help enroll them by:

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 LOQTORZI Solutions™ Co-Pay Savings Program only covers the cost of the drug. It does not cover costs associated with drug administration.

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 documentation required for claim submission, which can include, but is not limited to, an Explanation of Benefits (EOB) and claim form (e.g. CMS 1500), must be submitted within 365 days of the date that the primary claim was processed by the patient’s insurance to receive the co-pay savings benefit. Exceptions will not be made for claims submitted more than 365 days.

This co-pay assistance program is offered to, and intended for the sole benefit of, eligible patients and may not be utilized for the benefit of third parties, including, without limitation, third party payers, pharmacy benefit managers, or the agents of either. 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. Patient and provider agree to not seek reimbursement for any or all of the benefit received by the patient through the co-pay savings program. Patient and provider are responsible for reporting receipt of Co-Pay Savings Program benefits to any insurer, health plan, or other third party who pays for reimburses any part of the drug cost, as may be required.

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.