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.
