Example Request Letters

re: request for prior authorization

Patient Name: PATIENT NAME
Date of Birth: DOB
Medication Prescribed: MEDICATION SIG QUANTITY

Dear Pharmacy Benefits Administrator:

The patient captioned above has been seen and evaluated in our clinic. The evaluation included history taking, an appropriate examination, and a review of the patient’s medical record by a practitioner licensed to practice in the state of California. Based on this evaluation, we have determined that the medication and dosing listed above is medically necessary for treatment of the patient’s bona fide medical condition. Continued treatment with the requested medication is vital to prevent a relapse of the patient's condition that could result in hospitalization, permanent disability, or death. Any readily-available formulary information you might have provided for us was thoroughly reviewed, and no formulary agents were found which could safely be substituted for the medication prescribed.

As medical necessity has been established, you should not require information (such as other agents tried and failed, diagnosis, medical history) that pertains only to medical decision making. We would be happy to provide such information if given a signed statement by a duly licensed physician that s/he is making medical decisions regarding the patient’s care and will accept liability for such decisions.

Please note that in cases where medical necessity has been clearly established and coverage for medications is deferred or denied, placing our patients at risk, our protocol is to report such denials of medically necessary treatment directly to the California Department of Managed Health Care.

Thank you for your timely assistance in getting your customer and our patient needed care.

Sincerely,

Your Friendly Physician, MD