RE: Member Name: Member Number: Group Number: REQUEST: Authorization for treatment with ERLEADA™ (apalutamide) DIAGNOSIS: DOSE AND FREQUENCY: REQUEST TYPE: Standard EXPEDITED Dear : I am writing to support my request for an authorization for the above-mentioned patient to receive treatment with request is supported by the following: ERLEADA™, [insert indication]. My Summary of Patient’s Diagnosis Summary of Patient History Rationale for Treatment Considering the the full Prescribing Information supporting uses of believe patient’s history, condition, and ERLEADA™, I treatment with at this time is warranted, appropriate, and medically necessary, and should be a covered and ERLEADA™ reimbursed service. Please see the accompanying [peer reviewed journal, supporting clinical guidelines, FDA approval letter and] full Prescribing Information for that provide additional clinical information to support my ERLEADA™ recommendation for for this patient. ERLEADA™ Given the urgent nature of this request, please provide a timely authorization. Contact my office at if I can provide you with any additional information. Sincerely, If this request is denied, I am requesting an expedited Exception review by a professional in my specialty. Enclosures [Include full Prescribing Information and the additional support noted above]
RE: Member Name: Member Number: Group Number: REQUEST: Authorization for treatment with ERLEADA™ (apalutamide) DIAGNOSIS: DOSE AND FREQUENCY: REQUEST TYPE: Standard EXPEDITED Dear : I am writing to support my request for an authorization for the above-mentioned patient to receive treatment with ERLEADA™, [insert indication]. My request is supported by the following: Summary of Patient’s Diagnosis Summary of Patient History Rationale for Treatment Considering the patient’s history, condition, and the full Prescribing Information supporting uses of ERLEADA™, I believe treatment with ERLEADA™ at this time is warranted, appropriate, and medically necessary, and should be a covered and reimbursed service. Please see the accompanying [peer reviewed journal, supporting clinical guidelines, FDA approval letter and] full Prescribing Information for ERLEADA™ that provide additional clinical information to support my recommendation for ERLEADA™ for this patient. Given the urgent nature of this request, please provide a timely authorization. Contact my office at if I can provide you with any additional information. Sincerely, If this request is denied, I am requesting an expedited Exception review by a professional in my specialty. Enclosures [Include full Prescribing Information and the additional support noted above]
erleada-sample-letter-of-medical-necessity.docx