((Date))
((Insurance Company))
Attn: ((Contact name if available))
((Address))
((City, State Zip))
((Fax #))
Patient Name:
((Insert patient's name))
Policy Number: ((Insert Policy Number))
Group Number: ((Insert Group Number))
Re: Authorization for CellCept® (mycophenolate mofetil)
Please see the enclosed documentation demonstrating the medical necessity of CellCept for my patient,
((patient name)). ((He/She)) requires prevention of ((renal/cardiac/hepatic)) allograft rejection subsequent
to a ((kidney/heart/liver)) transplant. I would appreciate prompt review of the information and authorization
for CellCept.
Patient’s Clinical History
((Patient’s name)) is a ((age))-year-old ((male/female)) who received a ((kidney/heart/liver)) transplant on
((date)). ((Provide rationale for prophylaxis. For example, this includes brief description of the patient’s
immunosuppressive regimen and other factors that impact your treatment selection. Include supporting
medical records [see Enclosures section below].))
Rationale and Treatment Information
CellCept was first approved by the FDA on May 3, 1995, and is indicated for prevention of renal,
cardiac, or liver allograft rejection in combination with cyclosporine and corticosteroids. CellCept is the
2-morpholinoethyl ester of mycophenolic acid (MPA), an immunosuppressive agent. CellCept is rapidly
absorbed and metabolized to form MPA, a potent, selective, uncompetitive, and reversible inhibitor of
inosine monophosphate dehydrogenase (IMPDH), and therefore inhibits the de novo pathway of guanosine
nucleotide synthesis without incorporation into DNA. MPA sharply inhibits the growth and multiplication
of lymphocytes and prevents the formation of lymphocyte and monocyte glycoproteins that are involved in
intercellular adhesion to endothelial cells. MPA may also inhibit recruitment of leukocytes into sites of
inflammation and graft rejection.
I would like to treat ((patient name)) with CellCept. Please promptly review this information for
authorization of CellCept for my patient. ((He/She)) is at risk for ((renal/cardiac/hepatic)) allograft
rejection and requires immediate prophylaxis. I can be reached at ((phone number)) for additional
information and discussion. Thank you for your prompt attention to this matter.
Sincerely,
((Physician Name))
Enclosures ((Suggested)):
 CellCept package insert
 Patient clinical/surgical notes & relevant laboratory reports
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