Letter of Medical Necessity

Aetna

1234 Ranch Rd

San Diego, CA 92102

(760) 937-5480

Member name: John Smith

Member date of birth: 10/05/1987

Subscriber number: 12345

Group number: 6789

Request for approval of BRUKINSA (zanubrutinib)

Dear [Medical Reviewer name],

I am writing to [request prior authorization/document medical necessity] for my patient, [Patient name]. I have prescribed BRUKINSA as a treatment for [add diagnosis, ICD-10 code, and description]. This letter provides details of the patient’s medical history and rationale for treatment.

Patient’s medical history:

[Provide brief clinical description of patient, rationale for using BRUKINSA, and treatment history. List all current and past therapies.]

Thank you for your consideration of this request. I look forward to your prompt review.

Sincerely,

[Physician signature]

Dr. Jane Doe

0919-BRU-PRC-007