Healthcare Professional Template Letter to Health Plan/PBM: Maintain Coverage for Current MS Medication
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- Vivian Alexis Dorsey
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1 Healthcare Professional Template Letter to Health Plan/PBM: Maintain Coverage for Current MS Medication Communicating requests about your patient s prescription drug coverage can yield positive results. This template can be adapted to request that a patient maintain their current coverage of a specific MS medication. Place your cursor and type the details regarding your patient s case while revising or deleting any copy that is not relevant to the situation. Suggestions to consider: Summary of MS and impact on patient s life Review the results of the patient s current and previous treatments (if applicable); include dates of each treatment, reason for medicine change; adverse events and/or relapse history Address any alternative therapies suggested by the insurance provider Cite any supporting information: eg, best practices/consensus statements, journal articles, or special considerations likely to affect the patient s medication adherence For this template, consider using this direct line of copy from the National Multiple Sclerosis Society Disease Management Consensus Statement: Movement from one disease-modifying medication to another should occur only for medically appropriate reasons. Presented by the International Organization of Multiple Sclerosis Nurses (IOMSN) in partnership with Bayer HealthCare Bayer HealthCare Pharmaceuticals Inc., Whippany, NJ All rights reserved G July 2014
2 Template Letter to Health Plan/PBM: Maintain Current Coverage [Date] [Health Plan Name] [Phone Number] [Fax Number] [ Address] Dear [Insert health plan/pbm name]: Subject: Continued coverage request for [patient name], [insurance ID #] for [medication name] Multiple sclerosis (MS) is an unpredictable, often disabling disease. Following an established treatment plan is the best possible strategy for managing MS, and finding a disease-modifying medication that fits the patient s needs is a key element of that strategy. Based on my considerable experience in making treatment choices among the approved medications for MS, I strongly encourage you to continue authorizing the above treatment choice for my patient. [Insert patient s name and brief medical history, including amount of time on medication, clinical experience with medication, and reasons it needs to continue: eg, positive effect on relapse, favorable sideeffect profile, no change in MRI]. Based on clinical presentation and radiologic activity, I believe this disease-modifying medication has helped stabilize the disease. Therefore, I believe it is necessary to maintain coverage for [medication name], which has provided my patient with clinical success. [If needed, insert additional paragraph about the clinical history of this particular patient.] [Address any alternatives suggested by the insurance provider.] [Cite any supporting information: eg, consensus statements, journal articles, or special considerations likely to affect medication adherence.] Please let me know if you require any additional information from my records. Thank you. [Signature] [Healthcare Professional Name] [Phone/Fax Number & Address]
3 Healthcare Professional Template Letter to Health Plan/PBM: Receive Access to Non-covered Drug: New Patient Communicating requests about your patient s prescription drug coverage can yield positive results. This template can be adapted to request that a new patient receive access to a drug that is not covered by his or her health plan. Place your cursor and type the details regarding your patient s case while revising or deleting any copy that is not relevant to the situation. Suggestions to consider: Summary of MS and impact on patient s life Address any alternative therapies suggested by the insurance provider Cite any supporting information: eg, best practices/consensus statements, journal articles, or special considerations likely to affect the patient s medication adherence. For this template, consider using this direct line of copy from the National Multiple Sclerosis Society Disease Management Consensus Statement: FDA-approved agents should be included in formularies and covered by third-party payers so that physicians and patients can determine the most appropriate agent on an individual basis. Presented by the International Organization of Multiple Sclerosis Nurses (IOMSN) in partnership with Bayer HealthCare Bayer HealthCare Pharmaceuticals Inc., Whippany, NJ All rights reserved G July 2014
4 Template Letter to Health Plan/PBM: Access to Non-covered Drug: New Patient [Date] [Health Plan Name] [Phone Number] [Fax Number] [ Address] Dear [Insert health plan/pbm name]: Subject: [New] coverage request for [patient name], [insurance ID #] for [medication name] Multiple sclerosis (MS) is an unpredictable, often disabling disease. Following an established treatment plan is the best possible strategy for managing MS, and finding a disease-modifying medication that fits the patient s needs is a key element of that strategy. Based on my considerable experience in making treatment choices among the available drug therapies for MS, I strongly encourage you to authorize the above treatment choice as discussed with my recently diagnosed patient. [Patient name] is unable to take the preferred formulary medication, [insert name of formulary medication(s)], because of [provide the results of clinical trial(s) with preferred formulary medication, including occurrence of relapse, MRI results, and safety and tolerability data]. [Insert paragraph about the clinical history of this particular patient and provide details about the necessity of requested medication: eg, the effect MS is having on patient, MRI readings, comorbidities, and the positive study results of requested medication.] [Cite any supporting information: eg, consensus statements, journal articles, or special considerations likely to affect medication adherence.] Please let me know if you require additional information from my records. Thank you. [Signature] [Healthcare Professional Name] [Phone/Fax Number & Address]
5 Healthcare Professional Template Letter to Health Plan/PBM: Receive Access to Non-covered Drug: Clinically Necessary Communicating requests about your patient s prescription drug coverage can yield positive results. This template can be adapted to request that a current patient receive access, based on clinical necessity, to a drug that is not covered by his or her health plan. Place your cursor and type the details regarding your patient s case while revising or deleting any copy that is not relevant to the situation. Suggestions to consider: Summary of MS and impact on patient s life Review the results of the patient s current and previous treatments (if applicable); include dates of each treatment, reason for med change; adverse events and/or relapse history Address any alternative therapies suggested by the insurance provider Cite any supporting information: eg, best practices/consensus statements, journal articles, or special considerations likely to affect the patient s medication adherence For this template, consider using this direct line of copy from the National Multiple Sclerosis Society Disease Management Consensus Statement: FDA-approved agents should be included in formularies and covered by third-party payers so that physicians and patients can determine the most appropriate agent on an individual basis. Presented by the International Organization of Multiple Sclerosis Nurses (IOMSN) in partnership with Bayer HealthCare Bayer HealthCare Pharmaceuticals Inc., Whippany, NJ All rights reserved G July 2014
6 Template Letter to Health Plan/PBM: Non-covered Drug: Clinically Necessary [Date] [Health Plan Name] [Phone Number] [Fax Number] [ Address] Dear [Insert health plan/pbm name]: Subject: [New] coverage request for [patient name], [insurance ID #] for [medication name] Multiple sclerosis (MS) is an unpredictable, often disabling disease. Following an established treatment plan is the best possible strategy for managing MS, and finding a disease-modifying medication that fits the patient s needs is a key element of that strategy. Based on my considerable experience in making treatment choices among the available drug therapies for MS, I strongly encourage you to authorize the above treatment choice as discussed with my patient. [Insert patient s name and brief medical history, including medication they are currently taking, amount of time on medication, their clinical experience with medication, and the reasons it is no longer appropriate: eg, relapse history, side-effect profile, MRI results]. It is my belief that this patient has a highly active disease, and it is essential to provide coverage for [medication name] based on medical necessity. [If needed, include additional clarification below] [Patient name] is unable to take the preferred formulary medication, [insert name of formulary medication(s)], because of [provide the results of clinical trial(s) with preferred formulary medication, including occurrence of relapse, MRI results, and safety/tolerability profile]. [Cite any supporting information: eg, consensus statements, journal articles, or special considerations likely to affect medication adherence.] Please let me know if you require additional information from my records. Thank you. [Signature] [Healthcare Professional Name] [Phone/Fax Number & Address]
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