[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-279536-105":53,"doc-detail-279536-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","sample-non-formulary-letter-of-medical-necessity-requesting-formulary-exception","Sample Non-Formulary Letter of Medical Necessity - Requesting Formulary Exception","","Template letter used by a physician to request an insurer’s approval of coverage for a non-formulary medication as a medically necessary treatment. The letter includes patient and insurance identifiers, a clinical summary covering medical history and diagnosis, prior treatments and responses, and the physician’s rationale for the requested therapy. 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The template instructs healthcare providers or staff to review the insurer’s website or contact customer service for specific forms that may need to be completed and included when requesting a formulary exception.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},279536,1790008232,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},34359740700684,"https://ap-avatar.wpscdn.com/avatar/1f400023980c374ae676?_k=1777273430885731487","| \u003Cbr>Sample Non-Formulary Letter of Medical Necessity\u003Cbr>[Physician Letterhead]\u003Cbr>[Date]\u003Cbr>[Insurance Company Name] Insured: [Patient Name]\u003Cbr>Policy Number: [Patient’s Insurance ID Number]\u003Cbr>To whom it may concern,\u003Cbr>I am writing on behalf of my patient,[Patient Name], to request that you approve coverage for [PRODUCT] as a medically necessary treatment for [Patient Name]’s [Patient’s diagnosis, date of diagnosis] . This letter provides information about my patient’s medical history, diagnosis, and details regarding the medical necessity of the requested treatment with [PRODUCT] .\u003Cbr>Summary of Patient’s History\u003Cbr>[Note: Exercise your medical judgment and discretion when providing a diagnosis and characterization of the patient’s medical condition.]\u003Cbr>You may want to include:\u003Cbr>• [Patient’s history, diagnosis, and current condition]\u003Cbr>• [Patient’s previous treatments/and response to treatment]\u003Cbr>• [Summary of your professional opinion of the patient’s prognosis or disease progression without treatment with PRODUCT]\u003Cbr>Rationale for Treatment\u003Cbr>Given the patient’s medical history and current clinical status,[Patient Name] is appropriate for the approved indication for [PRODUCT], and I believe treatment with [PRODUCT] is warranted, appropriate, and medically necessary. The accompanying package insert provides the approved clinical information for [PRODUCT] .\u003Cbr>If you have further questions, please contact my office at [physician’s primary phone.]\u003Cbr>Sincerely,\u003Cbr>[Insert physician name and participating provider number]\u003Cbr>Enclosures\u003Cbr>Note to healthcare provider or staff: Review the insurer’s website or contact their customer service for specific forms that may need to be completed and included for requesting a formulary exception.\u003Cbr>The information contained in this template letter is provided by Pfizer for informational purposes for patients who have been prescribed a Pfizer medication. There is no requirement that any patient or healthcare provider use any Pfizer product in exchange for this information, and this template is not meant to substitute for a prescriber’s independent medical decision-making. |  |\n| --- | --- |\n| | © 2025 Pfizer Inc. All rights reserved. March 2025 PP-UNP-USA-5789 |","cbCaiaX4sWd8Vjnr","https://ap.wps.com/l/cbCaiaX4sWd8Vjnr","pdf",117835,"English","# Letter Header Details\n# Patient and Insurance Information\n# Request Statement and Medical Necessity Summary\n# Summary of Patient’s History\n## Prior Treatments and Response\n## Prognosis Without Treatment\n# Rationale for Treatment\n# Contact Information and Signature\n# Enclosures and Provider Notes","[{\"question\":\"What information does the non-formulary medical necessity letter include?\",\"answer\":\"It includes the physician letterhead, date, insurer name, insured patient name, policy number/insurance ID, and the requested product along with the patient’s diagnosis and date of diagnosis placeholders.\"},{\"question\":\"How should the physician justify medical necessity in the letter?\",\"answer\":\"The physician states that the patient’s history and current clinical status support the approved indication for the requested product and that the treatment is warranted, appropriate, and medically necessary.\"},{\"question\":\"Are there notes about additional forms or guidance for providers?\",\"answer\":\"Yes. The template instructs healthcare providers or staff to review the insurer’s website or contact customer service for specific forms that may need to be completed and included when requesting a formulary exception.\"}]","Sample Non-Formulary Letter of Medical Necessity - Requesting Formulary Exception | PDF",1789522558]