Prior Authorization Appeal Letter Tool

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Dermatologic disease with ICD-10 diagnosis code

Name of drug

Alternative treatment drug options

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

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Patient name

Patient health insurance identification number

Patient date of birth

Date of prior authorization

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I have previously prescribed this patient the following therapies (optional):

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

Reasoning: {{ medication.stopReason }}

Name of medication

Dates prescribed

From

Reason for stopping medication

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Download Letter

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Streamline appeals for over 70 dermatology drugs with our letter tool. Create customizable letters with medical rationales and references written by AAD members. Please note that personal information entered into the prior authorization tool is not saved by the AAD nor shared with any entity.

Related AAD/A resources

Tool Drugs & Diseases

View a full list of drugs and dermatologic diseases in the tool.

Impact on Dermatologists

Learn about prior authorization’s negative impact on dermatologists.

Best Practices

See our top strategies for streamlining your appeals process.

Workflow

View workflow tips that can help you improve the efficiency of appeals.

Resources

See additional guides and articles to help you with prior authorization.

Prior Authorization Appeal Letter Tool

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Dermatologic disease with ICD-10 diagnosis code

Name of drug

Alternative treatment drug options

Name of medical director

Insurance company name

Insurance company address

Insurance company city, state, zip

Patient name

Patient health insurance identification number

Patient date of birth

Date of prior authorization

I have previously prescribed this patient the following therapies (optional):

{{ medication.medName }}

Name of medication

Dates prescribed

Reason for stopping medication

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Prior Authorization Appeal Letter Tool

{{ steps[index] }}

Dermatologic disease with ICD-10 diagnosis code

Name of drug

Alternative treatment drug options

Name of medical director

Insurance company name

Insurance company address

Insurance company city, state, zip

Patient name

Patient health insurance identification number

Patient date of birth

Date of prior authorization

I have previously prescribed this patient the following therapies (optional):

{{ medication.medName }}

Name of medication

Dates prescribed

Reason for stopping medication

Related AAD/A resources

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