The UDENYCA® Reimbursement and Billing Guide is a step-by-step guide featuring key coding and coverage details that may help facilitate appropriate billing and reimbursement for UDENYCA® therapy. The guide provides an overview of the UDENYCA® treatment approval and reimbursement processes.
Before administering UDENYCA®, complete a product-specific benefits verification to assess patient insurance coverage, benefits details, and payer policy coverage decisions.
Coherus COMPLETETM can assist patients with benefits verification. The Coherus COMPLETETM Provider Portal provides a streamlined process:
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:
Document medical necessity of the patient
*NCCN guidelines, refer to Clinical Practice Guidelines of Oncology (NCCN guidelines)
Provider offices may use the services offered by Coherus COMPLETETM that include but are not limited to:
The Coherus COMPLETETM Co-Pay Assistance Program provides for $0 out-of-pocket cost for each UDENYCA® dose. Our program can help eligible patients* who are commercially insured with out-of-pocket costs for UDENYCA®.
If at any time a patient starts receiving coverage through a federal, state, or government-funded healthcare program, the patient will no longer be eligible for the program. The patient MUST contact Coherus COMPLETETM at 844-4-UDENCYA / 1-844-483-3692 to report the change in eligibility status.
Restrictions may apply and not valid where prohibited by law. Coherus may revise or terminate this program without notice at any time.
Following administration of UDENYCA® to the patient, submit a claim to the insurance provider. Coherus COMPLETETM can provide information on the buy-and-bill process to aid in claims submissions on behalf of patients.
Injectable physician-administered products are typically covered under the medical or Part B benefit, though some payers may require coverage under the pharmacy or Part D benefit. Coverage details can be determined during the benefits verification process.
The reimbursement rates of injectable physician-administered drugs covered under the medical or Part B benefit may depend on site of care, payer, and drug-specific information.
Regularly review insurance provider payments to the office and reconcile reimbursement of both primary and secondary insurance providers.
For more information on payment rates for injectable drugs in freestanding infusion centers/physician offices and hospital outpatient departments, consult the Billing and Coding Guide.
Medical Claims Submission: Providers
There are three ways for a provider to submit claims for reimbursement to the Co-Pay Assistance Program:
Electronically (click to learn more)
Electronic secondary payer billing (ESP billing) allows UDENYCA® (pegfilgrastim-cbqv) co-pay claims to be submitted and processed like a secondary payer.
Submit required documentation to:
PO Box 1349
Wake Forest, NC 27588
or via fax:
Please ensure the claim documentation clearly states the CPT/Q-Code, NDC, and/or drug name as well as the remaining out-of-pocket expense for UDENYCA® (pegfilgrastim-cbqv).
FOR CLAIM SUBMISSION FOR VIRTUAL DEBIT CARD REIMBURSEMENT:
Please fax the Virtual Debit Card Fax Coversheet* with the required documentation to 1-888-481-0544.
For Pharmacy Benefit Claims
||Set-up Coherus COMPLETE™ in your billing system (only requires set-up once)|
||Biller appends Coherus COMPLETE™ to the claim as a secondary payer after UDENYCA® (pegfilgrastim-cbqv) is administered|
||After payment is received from the primary payer, balance billed to Coherus COMPLETE™ like a secondary payer|
||Claims are electronically routed to Coherus COMPLETE™ Co-Pay Assistance Program via clearinghouse|
||Payment made to provider|