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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)
*****DISCLOSURE STATEMENT***** This transmission may contain information which is confidential, proprietary and privileged. If you are not the individual or entity to which it is addressed, note that any review, disclosure, copying, retransmission or other use is strictly prohibited. If you received this transmission in error, please notify the sender immediately and delete the material from your system.
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
*****DISCLOSURE STATEMENT***** This transmission may contain information which is confidential, proprietary and privileged. If you are not the individual or entity to which it is addressed, note that any review, disclosure, copying, retransmission or other use is strictly prohibited. If you received this transmission in error, please notify the sender immediately and delete the material from your system.

Source: http://imap.benefitallies.com/media/restat/pdf/prescriptions/Questionnaire-_Cymbalta_83112_1.pdf

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