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This form is used to request prior authorization for the non-preferred medication Cymbalta® (Duloxetine) under New Hampshire Medicaid guidelines, detailing patient information and clinical history

How to fill out cymbalta duloxetine new hampshire

How to fill out Cymbalta® (Duloxetine) New Hampshire Medicaid Prior Authorization/Non-Preferred Drug Approval Form

1. Obtain the New Hampshire Medicaid Prior Authorization/Non-Preferred Drug Approval Form for Cymbalta® (Duloxetine).
2. Fill in the patient’s personal information, including name, date of birth, and Medicaid ID number.
3. Provide the prescribing physician's information including name, contact details, and NPI number.
4. Indicate the diagnosis for which Cymbalta® is being prescribed, along with relevant medical history.
5. Detail any previous treatments the patient has received for this condition, including medication names and outcomes.
6. Include any clinical rationale for using Cymbalta®, explaining why other treatments were ineffective or inappropriate.
7. Sign and date the form, ensuring all required fields are completed.
8. Submit the form to the appropriate Medicaid office for review.

Who needs Cymbalta® (Duloxetine) New Hampshire Medicaid Prior Authorization/Non-Preferred Drug Approval Form?

1. Patients prescribed Cymbalta® (Duloxetine) who are enrolled in New Hampshire Medicaid.
2. Healthcare providers seeking reimbursement for prescribing Cymbalta® for patients under New Hampshire Medicaid.

People Also Ask about

What tier drug is Cymbalta?

Alternative Medications to Cymbalta Lexapro. Lexapro (escitalopram) is an alternative to Cymbalta that might be good for people who are concerned about Cymbalta's effects when used long-term. Effexor (venlafaxine) Prozac (fluoxetine) Wellbutrin (bupropion)

Is Cymbalta a sedating or energizing?

Cymbalta (duloxetine) is a prescription medication that's FDA approved for depression, anxiety, and different types of pain. It can cause sleep issues for some people, including both drowsiness and insomnia.

Is there a difference between Cymbalta and duloxetine?

Cymbalta is available as a generic drug called duloxetine. A generic drug is an exact copy of the active drug in a brand-name medication. The generic is considered to be as safe and effective as the original drug. Generics tend to cost less than brand-name drugs.

Why do people stop taking Cymbalta?

Mood changes: Some people on Cymbalta experience worsening depression or anxiety, or even have suicidal thoughts. [3] If you notice your mood getting worse, talk to your doctor right away about stopping or switching medications.

What is the downside of Cymbalta?

Downsides Severe skin reactions and urinary retention have also been reported with Cymbalta. An increased risk of suicidal thoughts, especially in young adults under the age of 24 (similar to other antidepressants). Associated with a discontinuation syndrome if stopped abruptly or even when tapered.

Does Medicaid pay for Cymbalta?

If you don't have employer-provided health insurance, Medicaid and Medicare may also provide some coverage for Cymbalta. Each state has different rules about what types of medications are covered under Medicaid and Medicare programs, so check with your local program administrator before filling a prescription.

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What is Cymbalta® (Duloxetine) New Hampshire Medicaid Prior Authorization/Non-Preferred Drug Approval Form?

Cymbalta® (Duloxetine) New Hampshire Medicaid Prior Authorization/Non-Preferred Drug Approval Form is a document required by New Hampshire Medicaid that must be filled out to obtain approval for the use of Cymbalta® as a non-preferred medication under the state's Medicaid program.

Who is required to file Cymbalta® (Duloxetine) New Hampshire Medicaid Prior Authorization/Non-Preferred Drug Approval Form?

Healthcare providers or prescribers who want to prescribe Cymbalta® (Duloxetine) to Medicaid patients are required to file this form to seek prior authorization from New Hampshire Medicaid.

How to fill out Cymbalta® (Duloxetine) New Hampshire Medicaid Prior Authorization/Non-Preferred Drug Approval Form?

To fill out the form, providers must complete all required sections with accurate patient information, medical history, and justification for the use of Cymbalta®, including previous treatments and their outcomes. Clear and concise documentation is essential.

What is the purpose of Cymbalta® (Duloxetine) New Hampshire Medicaid Prior Authorization/Non-Preferred Drug Approval Form?

The purpose of the form is to ensure that patients meet the clinical criteria for medication that may not be covered under the Medicaid program without prior authorization, and to facilitate appropriate use of healthcare resources.

What information must be reported on Cymbalta® (Duloxetine) New Hampshire Medicaid Prior Authorization/Non-Preferred Drug Approval Form?

The form requires reporting of patient demographics, the prescribing physician's information, details of the medical condition being treated, prior therapies tried and their effectiveness, and any relevant clinical notes that support the necessity of using Cymbalta®.