Letter

Patient assistance program cover letter

Attach this to a manufacturer patient assistance application. Most denials are paperwork problems, and a clear cover letter fixes several of them at once.

Before you send this

Proof of income for everyone in your household, which can be a tax return, recent pay stubs, a Social Security award letter, or an unemployment statement
Your prescriber signature on the application form itself
The exact insulin or drug name, strength, and dose
Whether you are uninsured, on Medicare, or underinsured, since the answer routes you to a different track

[DATE]

[PROGRAM NAME]

[PROGRAM ADDRESS OR FAX]

Re: Patient assistance application

Applicant: [YOUR NAME], DOB [DOB]

Medication requested: [DRUG NAME, STRENGTH, DOSE]

Prescriber: [PRESCRIBER NAME, NPI, PHONE]

To the review team,

Please find enclosed my completed application for [PROGRAM NAME].

Summary of my situation:

- I have [type 1 diabetes / insulin-dependent diabetes], diagnosed in [YEAR]. Insulin is not optional for me.

- Insurance status: [uninsured since DATE / Medicare Part D with plan NAME / commercially insured with unaffordable cost sharing].

- Household size: [NUMBER]. Annual household income: $[AMOUNT], which is approximately [PERCENT]% of the federal poverty level for my household size.

- Income documentation enclosed: [list exactly what you enclosed].

Financial hardship statement:

[Two to four honest sentences. Be concrete about numbers. Example: My monthly income after taxes is $X. My rent is $Y and my other fixed costs are $Z. My insulin and supplies currently cost $W per month at the pharmacy counter. In [MONTH] I [skipped doses / delayed a refill / went without CGM sensors] because I could not cover the cost.]

Notes for the reviewer:

- All income figures are [gross / net] and match the enclosed documentation.

- [If self-employed:] I do not receive pay stubs. I have enclosed [tax return / profit and loss statement / bank statements] instead.

- [If income recently changed:] My income changed on [DATE] because [REASON]. My prior tax return does not reflect my current situation. Enclosed is [documentation of the change].

- My prescriber has signed the required section and can be reached at [PHONE] to verify.

Please contact me at [PHONE] or [EMAIL] if anything is missing. I will supply it the same day. If this application is denied, please tell me the specific reason so I can correct it and reapply.

Thank you for reviewing my application.

Sincerely,

[YOUR NAME]

[MAILING ADDRESS]

[PHONE]

[EMAIL]

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