Treatment-naïve Patient Letter of Medical Necessity [Insert Date] RE: [Patient Name], [Patient Insurance ID Number] [Patient Date of Birth] Dear [Health Plan Contact Name]: This letter is regarding your coverage policy of [Enter Product Name] for my patient. I have reviewed your prescription drug policy; however, I feel that the most appropriate treatment for my patient falls outside the established policy. The most appropriate medication for initiating therapy for [his/her] relapsing multiple sclerosis (RMS) is [Enter Product Name]. I have evaluated my patient’s clinical symptoms and have provided a summary below: • • • [MRI data] [Physical Disability] [Relapse] I am prescribing [Enter Product Name] for my patient because I have concluded that it is the most appropriate therapeutic option, for the following reason(s): • • • • [Reason(s) this treatment is most appropriate for patient] [36T] [Further explanation for treatment choice] [36T] [Further explanation for treatment choice] [36T] [Further explanation for treatment choice] [If a step therapy before [Product Name] is required, include reason(s) why the step therapy would not be appropriate treatment for this patient.] Also, I ask that you review any clinical information I have submitted regarding my patient when considering my request. Below, I have indicated the additional information that I have submitted with this letter: ☐ Relevant medication history ☐ Anti-JCV antibody status ☐ MRI data ☐ Patient’s history of relapses ☐ DSS history [Provide reason that [Product Name] is the most appropriate treatment for this patient based on medical history, positive or negative anti-JCV antibody status, MRI data, history of relapses, or EDSS history.] Please feel free to contact me if you require further information regarding this request, and I look forward to your response as soon as possible. Sincerely, [Name] Patient to remain on current therapy Letter of Medical Necessity [Insert Date] RE: [Patient Name], [Patient Insurance ID Number] [Patient Date of Birth] Dear [Health Plan Contact Name]: This letter is regarding your coverage policy that requires me to take my patient off of [Enter Product Name]. I have reviewed your prescription drug policy; however, I feel that the most appropriate therapy at this time is to continue on [Enter Product Name] for my patient’s relapsing multiple sclerosis (RMS). I have been working with my patient since [Insert Date] to manage their disease. My patient has been on [Enter Product Name] since [Insert Date], and during this time my patient has been stable on therapy, as summarized below: • • [No new lesions as evidenced by MRI data] since [Insert Date] [No decline in disability status] as of [Insert Date] In my medical opinion, I believe that converting therapy is not the right choice based on my clinical judgment for the following reason(s): [Insert reason(s)]. I have included additional documentation regarding my patient, which supports my decision. I ask that you review the information I have indicated below when considering my request: ☐ ☐ ☐ ☐ ☐ Relevant medication history Anti-JCV antibody status MRI data Patient’s history of relapses EDSS history [Provide the reason that [Product Name] is the most appropriate treatment for this patient based on medical history, positive or negative anti-JCV antibody status, MRI data, history of relapses, or EDSS history.] Please feel free to contact me if you require further information regarding this request, and I look forward to your response as soon as possible. Sincerely, [Name] Patient to convert to another therapy Letter of Medical Necessity [Insert Date] RE: [Patient Name], [Patient Insurance ID Number] [Patient Date of Birth] Dear [Health Plan Contact Name]: This letter is regarding your coverage policy of [Enter Product Name] for my patient. I have reviewed your prescription drug policy; however, I feel that the most appropriate treatment for my patient falls outside the established policy. The appropriate therapy at this juncture is to discontinue [Enter Product Name] and to prescribe [Enter Product Name] to treat my patient’s relapsing multiple sclerosis (RMS). I have been working with my patient since [Insert Date] to manage their disease. They have been on [Enter Product Name] since [Insert Date]. My main concerns regarding my patient’s current medication include • [Reason(s) previous treatment(s) unsuitable] • [35T] • [35T] Therefore, I am prescribing [Enter Product Name] for my patient because I have concluded that it is the most appropriate therapeutic option for the following reason(s): • • • • [Reason(s) this treatment is most appropriate for patient] [35T] [Further explanation for treatment choice] [35T] [Further explanation for treatment choice] [35T] [Further explanation for treatment choice] [If a step therapy before [Product Name] is required, include reason(s) why the step therapy would not be appropriate treatment for this patient.] Additionally, I ask that you review the clinical information I have submitted, which supports my decision to change medication. Below, I have indicated the additional information that I have submitted with this letter: ☐ Relevant medication history ☐ Anti-JCV antibody status ☐ MRI data ☐ Patient’s history of relapses ☐ EDSS history [Provide reason that [Product Name] is the most appropriate treatment for this patient based on medical history, positive or negative anti-JCV antibody status, MRI data, history of relapses, or EDSS history.] Please feel free to contact me if you require further information regarding this request and I look forward to your response as soon as possible. Sincerely, [Name]
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