DUR Statement Template

My name is XXX and I am a [patient/caregiver/loved one] who has spent XXX years [living/working with/caring for someone] with [disease]. [If relevant, add professional background.]  I am asking you to support coverage for [treatment] without restrictions or barriers that would block access to patients who may benefit.

[Disease state] affects XXX people worldwide.  According to data from [source], approximately XXX patients whose condition makes them amenable to this treatment live in our state.  [Disease state] affects patients by…  It is [chronic/fatal/debilitating] and typically results in…  My personal experience with the disease is…

This treatment helps patients by…  My personal experience with [treatment] is…  It [has improved/would improve] my life by…  Without access to this treatment, I would…

Clinical data shows that the treatment is effective.  For example, according to [source], patients [were able to/didn’t have to]…  My experience reflects…  This treatment is [different from/complementary to/superior to] existing treatments because…  This treatment is important to patients because…

Again, I ask that you support coverage for [treatment] according to the FDA label without requirements like [“fail first,” step therapy, invasive testing, and/or other requirements] that will limit patient access to this treatment.

Thank you for your consideration.