Resources

Access helpful resources for your
patients and practice.

Program Overview Brochure

This brochure provides an overview of the support services provided by UDENYCA SolutionsTM. 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.

Patient Consent Form

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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.

UDENYCA Sample Claim Form 1450

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

UDENYCA Sample Claim Form 1500

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

Sample Coding Claim Form (CMS 1450) for ONBODY

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

Sample Coding Claim Form (CMS 1500) for ONBODY

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

UDENYCA Coding Flashcard

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

Product Fact Sheet Prefilled Syringe

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

Product Fact Sheet Autoinjector

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

Product Fact Sheet ONBODY

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

Product Fact Sheet: All 3 presentations

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This fact sheet includes all 3 UDENYCA presentations. It contains important information related to ordering, coding and billing.

Letter of Medical Necessity

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Prior to utilizing UDENYCA, 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.

Foundations and other Resources (Alternative Funding)

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

UDENYCA CO-PAY SAVINGS SUPPORT PROGRAM TERMS AND CONDITION

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 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 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.

Program Overview Brochure

Enrollment Form

Patient Consent Form

UDENYCA Sample Claim Form 1450

UDENYCA Sample Claim Form 1500

Sample Coding Claim Form (CMS 1450) for ONBODY

Sample Coding Claim Form (CMS 1500) for ONBODY

UDENYCA Coding Flashcard

Product Fact Sheet Prefilled Syringe

Product Fact Sheet Autoinjector

Product Fact Sheet ONBODY

Product Fact Sheet: All 3 presentations

Letter of Medical Necessity

Letter of Appeals

Foundations and other Resources (Alternative Funding)

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