PRACTICE RESOURCES

Explore Helpful Resources for your
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 Solutions™ 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 Sheet (CMS 1450 form for Hospital Inpatient Claims)

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 Sheet (CMS 1500 form for Outpatient Claims)

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.

Product Replacement Program Information

This document provides an overview of program guidelines and the form that must be completed in order to request product through the program.

Alternative Funding Resources

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

Patient Assistance Refill Request Form

Please use this form to request additional product through the patient assistance program for a specific patient if that patient is already enrolled and utilizing the program.

Virtual Debit Card Fax Request

Please use this form to request payment from the co-pay savings program to ensure payment is made through a virtual debit card.

Have questions?

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

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 drug 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-ofpocket expenses. The amount of the program’s benefits cannot exceed the patient’s out-of-pocket expenses for the cost of LOQTORZI™

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 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.