Letter of Medical Necessity

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]