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PRIOR AUTH CRITERIA- CYMBALTA (duloxetine)
(Page 1 of 2)
Prescriber Last Name:
Prescriber First Name:
Prescriber Phone:
_ Prescriber Fax:
Patient
ID#_
DOB

**FAILURE TO COMPLETE THE FORM MAY RESULT IN AN AUTOMATIC DENIAL**
Chronic musculoskeletal pain (continue on page 2) 2. Is the patient currently stable on the medication? a. If Yes, provide the date therapy was initiated _____________________ 3. Is the patient currently taking a Monoamine Oxidase Inhibitor? Ex. Emsam, Marplan, Nardil, Parnate (tranylcyromine)
4. Does the patient have a history of myocardial infarction or unstable coronary artery disease? Yes No
If YES, please specify:
5. Does the patient have a history of recurrent seizures? 6. Does the patient have an estimated CrCl <30ml/min?
7. If diagnosis is DEPRESSION:
a. Has the patient tried and failed a 30-day supply of an SSRI? Yes No b. If Yes, provide the date therapy was initiated ___________________________ 8. If diagnosis is DIABETIC PERIPHERAL NEUROPATHY or FIBROMYALGIA, has the patient been treated with any
of the following?
Check all that apply:

(continued on page 2)
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PRIOR AUTH CRITERIA- CYMBALTA (duloxetine) (Page 2 of 2)

Patient
ID#_
DOB

9. If diagnosis is CHRONIC MUSCULOSKELETAL PAIN:
a. Please indicate the patient’s diagnosis. Check all that apply and include chart notes as documentation: _osteoarthritis / DJD of the knee present for at least 3 months _chronic low back pain present for at least 6 months and accompanied by radicular signs or symptoms chronic low back pain present for at least 6 months without radicular signs or symptoms
b. Has the patient tried and failed any of the following? Check all that apply.
c. Does the patient have signs and/or radiographic or electrophysiologic evidence of any of the following? Check all that apply:
high grade spondylolisthesis (grade 3 or 4) 10. Are there other medical reasons for prescribing Cymbalta?
11. Prescriber signature or name and title of staff member providing answers
Send or Fax completed form to:
QUESTIONS PLEASE CALL:
11900 W. Lake Park Dr.
877-329-7279
Milwaukee, WI 53224
877-526-9906
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Source: http://imap.benefitallies.com/media/restat/pdf/prescriptions/Questionnaire-_Cymbalta_83112_1.pdf

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