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Yes No If the diagnosis is diabetic neuropathy has the member used at least TWO of the following formulary drugs or for the treatment of diabetic neuropathy prior to the initiation of or are any two of these medications likely to cause an allergy/adverse reaction or other harm Page 1 of 2 4. What is the member s diagnosis or indication please specify 2. Yes No If the diagnosis is depression has the member used at least TWO formulary drugs from any of the following classes SSRIs or SNRIs e.g....
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