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Medical Necessity Form And Sample Letter

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Sample Letter of Medical Necessity

Please t ranslate t his s ample l etter o n t o y our o wn p hysician’s l etterhead b efore p rinting.

[Date]

[Prescriber N ame]

[Your A ddress]

[Your C ity, S tate, Z IP]

[Your p hone n umber]

[Tax I D N umber]

[DEA N umber]

[Name o f R x P lan]

[Address o f R x P lan]

Re: A uthorization f or Q symia® ( phentermine a nd t opiramate e xtended-‐release) c apsules ( CIV) u se f or

[ Patient’s n

ame]

Member I D:

Group # :

Rx B in#:

Date o f B irth:

To W hom I t M ay C oncern:

I a m w riting t o d ocument t he m edical n ecessity o f Q symia® ( phentermine a nd t opiramate e xtended-‐release) c apsules

CIV f or m y p atient,

[ patient’s n

ame]. T he e nclosed d ocumentation p rovides i nformation a bout t he p atient’s m edical

history, d iagnosis, a nd m y t reatment r ationale.

Qsymia w as F DA a pproved o n J uly 1 7, 2 012 a s a n a djunct t o a r educed-‐calorie d iet a nd i ncreased p hysical a ctivity f or

chronic w eight m anagement i n a dults w ith a n i nitial b ody m ass i ndex ( BMI) o f 3 0 k g/m

o r g reater ( obese) o r 2 7 k g/m

or g reater ( overweight) i n t he p resence o f a t l east o ne w eight-‐related c omorbidity s uch a s h ypertension, t ype 2 d iabetes

mellitus, o r d yslipidemia.

[ Patient’s n

ame] w as o riginally d iagnosed w ith

[ disease(s)] i n [ year(s) o f d

iagnosis(es)].

[Include a d escription o f i nvestigation l eading t o d iagnosis(es) a nd a ny

t reatments that have never worked or stopped

]

working and those to which patient response was inadequate.

I p lan t o t reat

[ patient n

ame] w ith Q symia.

[ Include s tatement a bout w hy Q symia i s r ight f or t he p

atient].

In m y p rofessional o pinion, Q symia i s m edically n ecessary a nd i s t he a ppropriate t reatment c hoice f or m y p atient a t t his

time. T hus, Q symia s hould q ualify f or r eimbursement u nder m y p atient’s b enefit p lan. P lease f eel f ree t o c ontact m e i f

you r equire a dditional i nformation.

Sincerely,

Physician N ame, M D a nd S ignature

CC:

[ patient’s n ame]

Ref: Q symia® ( phentermine a nd t opiramate e xtended-‐release) c apsules C IV p ackage i nsert, 2 014

100427.02-USP

Medical Necessity Form And Sample Letter

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