Practice support tools

Tools and resources to help manage patients with endometriosis.


Benefits verification

Our insurance specialists can help verify patient coverage for ORILISSA. Find out more by calling Ori for Me at 1-844-674-3676 (1-844-OriForMe) or by filling out the Ori for Me referral form and faxing it to 1-833-674-5477 (ORILISSA).





Copay support

Eligible patients may pay as little as $5 a month with the ORILISSA Savings Card.*



*Available to patients with commercial prescription insurance coverage for ORILISSA® (elagolix) who meet eligibility criteria. Copay assistance program is not available to patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs (for example, Medicare [including Part D], Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs) or where prohibited by law or by the patient’s health insurance provider. If at any time a patient begins receiving prescription drug coverage under any such federal, state, or government-funded healthcare program, patient will no longer be able to use the ORILISSA Savings Card and patient must call Ori for MeTM at 1-844-OriForMe (1-844-674-3676) to stop participation. Patients residing in or receiving treatment in certain states may not be eligible. Patients may not seek reimbursement for value received from Ori for Me from any third-party payers. Offer subject to change or discontinuance without notice. Restrictions, including monthly maximums (maximum benefit of $200), may apply. This is not health insurance. Please see full Terms and Conditions.




Prior authorization

CoverMyMeds

Some insurance plans may require a prior authorization for ORILISSA.





Medical exception form

Here are some resources to help you complete a medical exception form, also known as a letter of medical necessity (LMN):


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 US full Prescribing Information.


PDF FORM

ORILISSA medical exception form PDF download

Download a PDF of our medical exception form


 

OR

 

ONLINE FORM


Copy clinical rationale considerations 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.



Create full-form letter

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





Patient Assistance Program

Ori for Me can help patients with limited resources access ORILISSA through our Patient Assistance Program†



Eligible patients typically have no healthcare coverage for ORILISSA, and meet low-income criteria outlined at www.abbvie.com/pap

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.