Prescription Substitution Letter
| Below is a letter that you can send to your insurance
company IF they decide to substitute your physician prescribed
medications for their formulary alternate drugs. All medicines are NOT created equal and a change in your medications could affect your health. IF insurance companies want the right to prescribe drugs, they should be willing to stand behind that decision. Just copy and paste the letter to your letterhead and send it to your insurance company. Together we can make a difference. |
|
Patient's Prior Authorization for Therapeutic Substitution Date:____________________ My physician has prescribed_______________________ which I have been on and have found it well tolerated and is proven by my physician as medically necessary and therapeutic. Before I discuss with my physician changing to a.)_________________ and/or b.)____________________, Please provide the following: 1. a.) Your name/title:______________________ b.) Licensed Pharmacist: Yes / No 2. Do you carry medical insurance in the event of a negative outcome from substitution? No / If Yes,
name of your insurance carrier:____________________________ 3. a.) Are these drugs bioequivalent? Yes / No
d.) What is the allowable (by the FDA) variability in the strength/potency?_______ 4. a.) What is your profit margin for each medication? a.) ______________b.)____________ b.) What is your cost for a.) ___________________b.)______________ c.) What is your reimbursement for a.)___________ b.)_____________ 5. a.) What other incentives are built in to this substitution? Please explain.
b.) Is there a "bonus" for the individual who obtains the substitution? Yes / No . c.) Are there "performance" criteria by which one is considered, depending on the number or percentage of substitutions one obtains? Please explain.
Signed:_________________________________ Address:________________________________ ________________________________ ________________________________
|