HTML Preview Authorization Request Letter page number 1.
1
Drafting a Coverage
Authorization Request Letter
Step 1
Please see Important Safety Information on page 4 and full Prescribing Information and
Medication Guide. Please see Instructions for Use included with the device.
Coverage Authorization Requests and Appeals Guide
DRAFTING A COVERAGE AUTHORIZATION REQUEST LETTER
Most health plans require a coverage authorization request and supporting documentation to
process and cover a claim for biologic treatments. A coverage authorization allows the payer
to review the reason for the requested treatment and determine its medical appropriateness.
This resource, Step 1 Sample Process For: Drafting a Coverage Authorization Request Letter,
provides information to healthcare providers (HCPs) when drafting a Coverage Authorization Request
Letter. A list of sample payer requirements and a checklist are included below and outline what to
include in a Coverage Authorization Request Letter. Sample letters are attached to this document and
include information that many health plans require to process the coverage authorization request.
Plans often have specific Coverage Authorization Request Forms that must be used for requests.
These forms may be downloaded from each plan’s website. Follow the plan’s requirements when
requesting Taltz
®
(ixekizumab) injection (80 mg/mL). Otherwise treatment may be delayed.
COVERAGE AUTHORIZATION REQUESTS: GUIDANCE AND RECOMMENDATIONS
1. All Taltz Coverage Authorization Request Forms should be completed and submitted to the
plan by the HCP’s office
2. Your Taltz Patient Reimbursement Specialist (PRS) may be able to provide you with coverage
authorization requirements for specific plans and pharmacy benefit managers (PBMs). Benefit
verifications performed by the Taltz Together Hub and/or specialty pharmacies can assist with
identifying coverage authorizations, form requirements, and step edit therapies
3. FAX the completed Coverage Authorization Request Form to the health plan
4. FAX the Service Request Form (SRF) to Taltz Together at 1-844-344-8108
5. If the HCP expects that a plan-specified step edit therapy will not be well tolerated by the patient,
an appeal may be submitted to the plan to bypass this requirement. For more information, refer
to Step 3: Composing a Letter of Medical Necessity (LMN)
6. Plans will usually allow up to 3 levels of appeal for coverage authorization denials. The third
appeal may include a review by an external review board or hearing. Refer to Step 2: Preparing
a Coverage Authorization Appeals Letter
COVERAGE AUTHORIZATION CONSIDERATIONS
Verify and record that all of the coverage authorization requirements for the plan have
been met
If applicable, provide evidence that all step edit therapy prerequisites have been met. For step
edit therapy exception requests, when medically appropriate, include wording explaining why a
particular step edit therapy as required by the plan is not medically appropriate for the patient
Review the attached sample letters as examples
If required, use the health plan’s Coverage Authorization Request Form that can be found on the
plan’s website. Your Taltz PRS may also be able to assist you in locating the plan-specific form
The following information is presented for informational purposes only and is not intended to provide
reimbursement or legal advice. Laws, regulations, and policies concerning reimbursement are complex and
are updated frequently. While we have made an effort to be current as of the issue date of this document, the
information may not be as current or comprehensive when you view it. Providers are encouraged to contact
third-party payers for specific information on their coverage policies. For more information, please call
Taltz Together™ at 1-844-TALTZ-NOW (1-844-825-8966).