Medicare Compliance & Reimbursement

Pharmacies, take note: With a new plan year coming, chances are good that your customers will soon need to jump through some hoops to retain coverage for certain drugs.

To keep claims paid and care on track, work with customers' physicians as necessary using this exceptions request supplemental form.

Do this: To improve chances that a plan will grant an exception, recommend that the individual's physician send a version of this letter with the plan's exception request form, suggests the Medicare Rights Center. The letter should be printed on the physician's stationery.

DATE

Name of patient has been under my care for number of years. His/Her diagnoses are diagnoses. In order to appropriately treat Name of patient's medical condition, I have prescribed Name of medication, dosage and amount.

Name of medication is medically necessary for Name of patient because state reasons. If he/she cannot take this medication consequences of not taking the medication at issue.

No other medications in this class and category on the Name of plan formulary would be as effective in treating Name of patient because reasons.

Alternative medications in this class and category would cause Name of patient to experience list of serious adverse consequences.

The number of doses that is available under a dose restriction for the drug has been or is likely to be ineffective or adversely affect the drug's effectiveness or patient compliance.

Name of patient cannot afford the cost-sharing amount the plan has set for this medication. Since not taking Name of medication will Pick one of the following options: be less effective and/or cause adverse effects for the reasons stated above, I request that you cover Name of medication for Name of patient at a lower cost-sharing tier.

In my professional opinion, Name of patient must receive an expedited decision in order to obtain Name of medication immediately. Failure to get this medication quickly will seriously jeopardize Name of patient's life or health or ability to regain maximum function because state reasons.

Please contact me should you require any additional information. I can be reached at phone number.

Sincerely,

Physician's Full Name 

Source: Medicare Rights Center. Reprinted with permission. To access a version of the form in Microsoft Word, go to http://www.medicarerights.org/exceptionrequest_template.doc.