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Cymbal ta (duloxetine) PRIOR AUTHORIZATION FORM Coverage Criteria: Covered for the treatment of major depressive disorder OR generalized anxiety disorder when there is a documented failure to an 8-week

How to fill out cymbalta duloxetine prior authorization

How to fill out cymbalta duloxetine prior authorization:

1. Obtain the prior authorization form from your healthcare provider or insurance company.
2. Fill in your personal information such as your name, date of birth, and contact details.
3. Provide your insurance information including your policy number and group number.
4. Include the name and dosage of the cymbalta duloxetine medication that your healthcare provider has prescribed.
5. Attach any necessary supporting documentation such as medical records or a letter of medical necessity.
6. Review the form to ensure that all sections are completed accurately and legibly.
7. Sign and date the form before submitting it to your healthcare provider or insurance company.

Who needs cymbalta duloxetine prior authorization:

1. Individuals who have been prescribed cymbalta duloxetine by their healthcare provider.
2. Patients whose insurance plan requires prior authorization for this specific medication.
3. Those who are seeking insurance coverage for cymbalta duloxetine and need to meet the authorization requirements specified by their insurance company.

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