Patient support services and
programs to assist with access

Medicare and Patient Assistance

Patients receiving UDENYCA^® (pegfilgrastim-cbqv) with no insurance or who are insured with traditional Medicare fee-for-service (FFS) that demonstrate financial hardship and cannot afford their cost-sharing obligation may be eligible for patient assistance through the Patient Assistance Program (PAP). Patients with other government insurance, including Medicare Advantage, Medicare Part D, Fee-for-service Medicaid, Managed Medicaid, Veterans Affairs, Department of Defense, TRICARE, or any other insurance that is federally or state-funded are not eligible for Patient Assistance.

UDENYCA^® can be provided at no cost to eligible underinsured* patients with financial hardship* through the Patient Assistance Program (PAP).

Patient Eligibility Criteria (must meet all to qualify)

Patients Must:

• Be either: (a) uninsured; (b) functionally underinsured*; or (c) traditional Medicare FFS insured patient(s) that demonstrate financial hardship and cannot afford their cost-sharing obligation as evidenced by a signed attestation from their provider
• Have an adjusted annual household income of ≤ 500% of Federal Poverty Level (FPL)
• Complete and sign consent form and, when applicable, provide income documentation
• Be under the care of a U.S. licensed provider, and receive UDENYCA^® in an established practice located in the U.S. incident to the prescribing physician’s professional services in the outpatient setting
• Be a U.S. resident of any U.S. state
• Diagnosis and dosing are consistent with FDA-approved indication for UDENYCA^® (pegfilgrastim-cbqv)
• Not have any other financial support options
• The patient must receive the drug in an outpatient setting by the physician or physician office
• Adjusted annual household income of ≤ 500% of Federal Poverty Level (FPL)
• Patient must complete and sign the consent and, when applicable, provide income documentation
• Providers: For insured patients I understand that the Coherus Solutions^™ program does not provide free drug in the instance of an administrative error or a coverage restriction such as a step edit or others deemed as restrictions. For certain products where step edit may not be medically appropriate, and confirmed by the prescribing physician, the Coherus Solutions^™ program may consider enrollment following one level of appeal.Must be enrolled in Coherus Solutions^™
• Providers requesting more than six (6) PAP fills for the same patient will be required to provide written attestation on business letterhead reaffirming continued PAP necessity (DX, patient therapy log, etc.)
  
  The UDENYCA Solutions^™ Patient Assistance Program (PAP) only includes dispensing the UDENYCA^® pre-filled syringe.