Practice support tools

Tools and resources to help manage patients with endometriosis.


CoverMyMeds


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Medical Exception Template


We have created an online Medical Exception Resource for your use.


Typical elements of a Letter of Medical Necessity and frequently used supporting documents:

For prescription approval, third-party payers may require physicians to submit documentation of medical necessity to support coverage of the prescribed treatment. A Letter of Medical Necessity documents a patient’s medical history and diagnosis, and provides a medical justification for the prescribed treatment.


What is included in a Letter of Medical Necessity?

  • Reason for request
  • Reason for denial
  • Rationale to address each reason for denial, including relevant clinical rationale where applicable
  • Relevant overall patient medical history and current condition
  • Relevant cost information (if known)
  • Summary of your professional opinion of likely outcome with the treatment
  • Restatement of request for approval

A Letter of Medical Necessity is usually submitted as part of a more comprehensive medical exception request package. Many physicians submit additional supporting documents to the payer along with the Letter of Medical Necessity for clinical justification. Keep in mind that the specific coverage policies and processes vary by payer.


Frequently used supporting documents:

  • Any required appeal form from the insurer (if applicable)
  • Copy of the denial letter from the insurance company
  • Copy of the prescription
  • Patient’s signature on consent form for treatment
  • Patient’s complete medication profile including patient’s current, previous, and discontinued medications

The guidance presented here is for informational purposes only and is not intended to provide reimbursement or legal advice. AbbVie does not guarantee that the use of any information provided will result in coverage or payment by any third-party payer. You are responsible for the submission based on your clinical judgment.




As you navigate through the Medical Exception Resource, please make selections based on your clinical judgment for your specific patient. Based on your selections, the tool will generate pre-populated information consistent with the approved U.S. full Prescribing Information.


The Medical Exception Resource also provides 2 unique functions. You may:


1) Copy to clipboard. This functionality allows you to copy, then fully edit and transfer the pre-populated information to your own EMR or medical exception form.

and/or

2) Create full-form letter. This functionality contains additional fields for you to complete, based on your clinical judgment, and creates a full-form letter.


The guidance presented here is for informational purposes only and is not intended to provide reimbursement or legal advice. AbbVie does not guarantee that the use of any information provided will result in coverage or payment by any third-party payer. You are responsible for the submission based on your clinical judgment.


Copy to clipboard

Clinical rationale considerations you can include in your own medical exception letter or electronic medical records (EMR).


Create full-form letter

Includes clinical rationale considerations and additional fields for you to create a full-form letter.

Medical exception template


Clinical rationale considerations

Full-form letter



Please make selections based on your clinical judgment for your specific patient. Based on your selections, the tool will generate pre-populated information consistent with the approved U.S. full Prescribing Information.


My patient:

Please select all that apply.




Please note:

The guidance presented here is for informational purposes only and is not intended to provide reimbursement or legal advice. AbbVie does not guarantee that the use of any information provided will result in coverage or payment by any third-party payer. (You are responsible for the submission based on your clinical judgment.)


This information is provided for use by United States health care professionals only. It is not intended for patients.

This functionality allows you to copy, then fully edit and transfer the pre-populated information to your own EMR or medical exception form.


Medical Exception Template:





Please note:

The guidance presented here is for informational purposes only and is not intended to provide reimbursement or legal advice. AbbVie does not guarantee that the use of any information provided will result in coverage or payment by any third-party payer. (You are responsible for the submission based on your clinical judgment.)


This information is provided for use by United States health care professionals only. It is not intended for patients.

This functionality contains additional fields for you to complete, based on your clinical judgment for your specific patient, and creates a full-form letter.

Based on your selections, the tool will generate pre-populated information consistent with the approved U.S. full Prescribing Information.


Your details:


First full name:


Last full name:


Your contact number:



Payer details:


Payer's full name:


Department:


Street address:


Zip code:


City:


State:


Fax number (Optional):


Denial date (MM/DD/YYYY):


Denial reason:



Patient details:


Patient's full name:


Patient's contact number:


Date of birth (Optional) (MM/DD/YYYY):


Member ID:


Date diagnosed (Optional) (MM/DD/YYYY):


Description of patient's medical history:


My patient:

Please select all that apply.



Medical exception




Please note:

The guidance presented here is for informational purposes only and is not intended to provide reimbursement or legal advice. AbbVie does not guarantee that the use of any information provided will result in coverage or payment by any third-party payer. (You are responsible for the submission based on your clinical judgment.)


This information is provided for use by United States health care professionals only. It is not intended for patients.

This functionality allows you to generate a full-form letter PDF and transfer the pre-populated information to yourself.


Preview letter:

Date: {{vm.todaysDate | date:'MM/dd/yyyy'}}
Payer Name: {{vm.payerFullName}}
Payer Address: {{vm.payerAddress}}
{{vm.payerCity}} {{vm.payerState}} {{vm.payerZipCode}}
Payer Fax Number: {{vm.payerFaxNumber}}

Attn: {{vm.payerDepartment}}

Re: Coverage of {{vm.drugName}}
Patient Name: {{vm.patientFullName == 'The patient' ? '' : vm.patientFullName}}
Patient Date of Birth: {{vm.patientDOB}}
Patient Member ID: {{vm.patientMemberID}}

To whom it may concern,

I am writing to request approval of {{vm.drugName}} to treat my patient, {{(vm.patientFullName == 'The patient' ? '' : vm.patientFullName)}}. This product was denied on {{vm.payerDenialDate}} for the following reason(s): for the following reason(s): {{vm.payerDenialReason}}

The patient {{vm.patientFullName}} is a {{vm.patientAge}}-year-old male female other who has been diagnosed with moderate to severe pain associated with endometriosis.

The patient {{vm.patientFullName}} was diagnosed with moderate to severe pain associated with endometriosis on {{vm.patientDiagnosedDate}}. The patient {{vm.patientFullName}} 's medical history includes {{vm.patientMedicalHistory}}.

Approval is being requested for {{ vm.drugName }} based on my clinical opinion of the following clinical evidence and rationale:

If I can provide any additional information, please contact me at {{vm.phoneNumber}} to ensure the prompt approval of this course of treatment.

Regards,

{{vm.firstName}} {{vm.lastName}}






Please note:

The guidance presented here is for informational purposes only and is not intended to provide reimbursement or legal advice. AbbVie does not guarantee that the use of any information provided will result in coverage or payment by any third-party payer. (You are responsible for the submission based on your clinical judgment.)


This information is provided for use by United States health care professionals only. It is not intended for patients.