Access helpful resources for your
patients and practice.
Program Overview Brochure
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This brochure provides an overview of the support services provided by UDENYCA 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
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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, or the co-pay savings program.
PAP Enrollment Form
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This form should be used to enroll your patient into the patient assistance program.
Patient Consent
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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.
Sample Coding Sheet (CMS 1450 form for Hospital Inpatient Claims)
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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.
Sample Coding Sheet (CMS 1500 form for Outpatient Claims)
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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.
Coding Reference Guide
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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
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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.
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.
Product Replacement Request Form
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This form needs to be completed in order to request product through the product replacement program. Please see the Product Replacement Guidelines to understand program requirements.
Product Replacement Guidelines
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This document reviews the eligibility requirements for the product replacement program and explains how the program works.
Patient Assistance Refill Request Form
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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
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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 Coherus SolutionsTM resources, call 1-844-4-UDENYCA / 1-844-483-3692.
