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Please note All information below is required to process this request Mon-Fri 5am to10pm Pacific / Sat 6am to 3pm Pacific For real time submission 24/7 visit www. Medication history Does the member have a history of failure or intolerance to the following If yes please provide all relevant medications tried and failed Yes No generic Date Yes No Diclofenac generic Voltaren Yes No Ibuprofen generic Motrin Yes No generic Yes No Naproxen generic Yes No Other tier 1 non-steroidal anti-inflammatory...
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