It is important to establish medical necessity prior to treatment to prevent claim delays. Government and private insurers have varying criteria for determining if a treatment is medically necessary based on the patient's circumstances. Medicare uses National Coverage Determinations and private Medicare plans
(i.e., Medicare Advantage) use Local Coverage Determinations in order to ensure that the criteria for medical necessity are met. Private insurers can set their own criteria, although they're required to provide coverage that's in compliance with state and federal mandates.
Prior to treatment, an office should review and document the following to determine medical necessity:
In order to determine coverage of UDENYCA the payer needs to be contacted to complete a
benefit verification.
UDENYCA Solutions™ may be able to assist. Enroll your patient in UDENYCA Solutions™ and complete the benefit verification request and enroll your patient into any applicable patient support program available.
A benefit verification will:
Identify of payer medical necessity requirements to establish coverage determination
Prior authorization (PA) or pre-certification/pre-determination requirements
Identify drug specific PA forms or payer portals to process treatment approvals
Review additional resources* that support medical necessity for treatment regimen
*Refer to clinical guidelines (e.g., ASCO Guidelines, publications, etc.)
Provider offices may use the services offered by Coherus Solutions™ that include but are not limited to:
Benefit Verifications to identify payer medical necessity requirements
Identification of payer PA requirements
PA forms if required or recommended by payer
For additional payer policy information, please contact Coherus Solutions™ at 1-844-4-UDENYCA / 1-844-483-3692 or visit the or visit the Coherus SolutionsTM Provider Portal.
UDENYCA CO-PAY SAVINGS SUPPORT PROGRAM TERMS AND CONDITION
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 UDENYCA Co-Pay Savings Program, if a patient incurs a co-pay obligation for the cost of UDENYCA, and meets all eligibility requirements, Coherus may provide co-pay assistance for up to $15,000 per calendar year.
The UDENYCA 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 UDENYCA.
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.
