This letter template provides an example of the types of information that practices may provide to insurers when

responding to a request from a patient’s insurance company to provide a letter of medical necessity for

prescribing Sancuso® . A copy of the full Prescribing Information for Sancuso is located on the website (http://www.sancuso.com/hcp/share/pdf/SANCUSO-Full_PI.pdf) for your reference. You may want to consider including such information with the letter of medical necessity. Use of the information in this letter does not guarantee that the insurance company will provide reimbursement for Sancuso.

[DATE]

[Insert physician letterhead]

[Insert Insurance Company Name] Re: [Insert Patient Name]

[Insert Ins. Co. Medical Director Name] [Insert Insured ID #]

[Address:] [Insert Insured Patient Group #]

Re: Letter of Medical Necessity for Sancuso 3.1mg/24hr Patch

Dear Medical Review Officer:

I am writing to request Sancuso (Granisetron Transdermal System) 3.1mg/24hr Transdermal Patch for my patient, [PATIENT NAME], who has the following diagnosis relevant to this request: [Chemo induced nausea and vomiting (R11.2)] (CINV). Sancuso is indicated for the prevention of nausea and vomiting in patients receiving moderately and/or highly emetogenic chemotherapy for up to 5 consecutive days.

Note to prescribing physician: Exercise your medical judgment and discretion when providing a diagnosis and characterization of your patient’s medical condition.

[PATIENT NAME] was diagnosed with [CANCER DIAGOSIS] on [DATE]. As part of his/her treatment plan, [PATIENT NAME] [commenced/is scheduled for] a [moderately or highly] -emetogenic chemotherapeutic regimen consisting of [DESCRIBE CHEMO REGIMEN AND CYCLE].

Additionally, [PATIENT NAME] possesses several physiological or pathophysiological risk factors that increase [his/her] likelihood of developing CINV or preclude the use of oral antiemetics including [For example: age less than 60, female gender, prior history of CINV, anticipatory nausea and vomiting, prior history of hyperemesis gravidarum, anxiety-related mental health disorder, history of motion sickness, vestibular dysfunction, presence of a colostomy, oral mucositis, or dysphagia.]

It is my professional opinion that [PATIENT NAME] would not benefit from any of the preferred drugs on your plan formulary and, if the patient does not receive adequate prophylaxis to prevent CINV, [he/she] may experience prolonged nausea and vomiting.

Sancuso 3.1mg/24hr TransDermal Patch will allow [PATIENT NAME] to achieve optimal control of CINV.

I am requesting that [INSURANCE] approve coverage for request Sancuso 3.1mg/24hr TransDermal Patch for [PATIENT NAME]. The attached clinical records for [PATIENT NAME] document the medical necessity for use of Sancuso Patch and subsequent coverage as planned. If you have any additional questions regarding this request, please do not hesitate to contact the office. Thank you for your prompt attention to this matter.

Sincerely,

[PRESCRIBER NAME]

[LICENSE NUMBER]

[ADDRESS]

[PHONE]

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