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Step {{index}} of {{steps.length-1}}

Prior Authorization Drug Denial Letter Template

Complete the following steps to create an individualized letter appealing a denial for a prescribed treatment for your patient.

Alternative Treatment Drug Options

For step therapy protocols, select drug/treatment the insurance company is requiring you to prescribe your patient as an alternative treament (skip if not applicable)

* = required field

* = required field

* = required field

I have previously prescribed this patient the following therapies (optional):
{{ medication.medName }}

Prescribed from {{ convertDatePickerDate(medication.startDate) }} to {{ convertDatePickerDate(medication.endDate) }}

Reasoning: {{ medication.stopReason }}

Dates prescribed

* Please fill out all fields

Click the button below to download your prior-authorization letter template.
Download Letter

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