Authorization Request Letter
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1 HCPs can follow this format for patients who are NOT currently receiving treatment with Taltz® (ixekizumab) injection (80 mg/mL) Date Prior Authorization Department Name of Health Plan Mailing Address Re: Patient’s Name Plan Identification Number Date of Birth To whom it may concern: This letter serves as a coverage authorization request for Taltz® (ixekizumab) for patient’s name, plan identification, and group number for the treatment of diagnosis and ICD code .. Sincerely, Physician’s name and signature Physician’s medical specialty Physician’s NPI Physician’s practice name Phone Fax Encl: Patient’s name and signature Medical records Supporting documentation Photo(s) Clinical trial data Include patient’s medical records and supporting documentation, including clinical evaluation, scoring forms, and photos of affected areas.. 2 HCPs can follow this format for patients who HAVE been treated with Taltz® (ixekizumab) injection (80 mg/mL), and have had treatment interruptions Date Prior Authorization Department Name of Health Plan Mailing Address Re: Patient’s Name Plan Identification Number Date of Birth To whom it may concern: This letter serves as a coverage authorization request for Taltz® (ixekizumab) for patient’s name, plan identification, and group number for the treatment of diagnosis and ICD code ..
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