Dermatologist Templates

Ruxolitinib (Opzelura) - Letter of Medical Necessity (LOMN)

Click Here to Download the LOMN Ruxolitinib (Opzelura)

GVF wishes to acknowledge that Incyte Corp, maker of ruxolitinib (Opzelura), is a financial supporter of the Global Vitiligo Foundation. We are posting this letter of medical necessity (LOMN) because this is the first, and currently the only, FDA-approved drug for vitiligo repigmentation, and not because they are a financial sponsor. As other drugs are approved by the FDA, we will review the data and, if warranted, create a LOMN for that drug as well.

In-office Phototherapy Letter

Click Here to Download the In Office Phototherapy Letter (MS Word)

In-office Excimer Letter

Click Here to Download the In Office Excimer Letter (MS Word)

Home Phototherapy Letter

Click Here to Download the Home Phototherapy Necessity Letter (MS Word)

Pre-Authorization Request Template

Click Here to Download the Preauthorization Form (MS Word)

Want to see the letter before downloading it? See a copy of the letter here.

Letter of Medical Necessity

Click Here to Download the Medical Necessity Letter (MS Word)

Want to see the letter before downloading it? See a copy of the letter here.

Phototherapy dosing instructions and tracking

Click Here to Download the UVB Dosing Chart Log and Instructions

Notice:

The information provided in the document above should only be used under the guidance of your physician/doctor/medical professional.  Use your phototherapy device as you would a prescription medication under the direction of a physician. Like any medication, phototherapy can be harmful if not used properly.

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