Cymbalta (Duloxetine Hcl) Prior Authorization of Benefits Form
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Cymbalta (Duloxetine HCl) Prior Authorization of Benefits Form CONTAINS CONFIDENTIAL PATIENT INFORMATION Complete form in its entirety and fax to: Prior Authorization of Benefits Center at 844-512-9005 for retail pharmacy or 844-512-7027 for medical injectable. 1. Patient information 2. Physician information Patient name: _________________________________ Prescribing physician: _______________________________ Patient ID #: __________________________________ Physician address: _________________________________ Patient DOB: _________________________________ Physician phone #: _________________________________ Date of Rx: ___________________________________ Physician fax #: ____________________________________ Patient phone #: _______________________________ Physician specialty: _________________________________ Patient email address: __________________________ Physician DEA: ____________________________________ Physician NPI #: ___________________________________ Physician email address: ____________________________ 3. Medication 4. Strength 5. Directions 6. Quantity per 30 days Cymbalta (Duloxetine HCl) ______________________ _____________________ Specify: ________________________ 7. Diagnosis: ____________________________________________________________________________________ 8. Approval criteria: (Check all boxes that apply. Note: Any areas not filled out are considered not applicable to your patient and may affect the outcome of this request.) Major depressive disorder (MDD), depressive disorder or dysthymia: □ Yes □ No Patient has a diagnosis of MDD, depressive disorder or dysthymia. □ Yes □ No Has the patient been on Cymbalta (Duloxetine) in the past 180 days (medication samples/coupons/discount cards are excluded from consideration as a trial)? □ Yes □ No Has the patient had a trial (medication samples/coupons/discount cards are excluded from consideration as a trial) of and inadequate response or intolerance to two preferred antidepressants? [Please note: The preferred agents include amitriptyline HCl, amoxapine, bupropion HCl, citalopram hydrobromide, clomipramine HCl, desipramine HCl, doxepin HCl, escitalopram oxalate, fluoxetine HCl (except 60 mg tablets), fluvoxamine maleate tablets, imipramine HCl, imipramine pamoate, maprotiline HCl, mirtazapine, nefazadone HCl, nortriptyline HCl, paroxetine HCl, paroxetine ER, paroxetine CR, phenelzine sulfate, protriptyline HCl, sertraline HCl, tranylcypromine sulfate, trazodone HCl, trimipramine maleate, venlafaxine HCl, venlafaxine ER.] www.HealthyBlueSC.com BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC. an independent company, for services to support administration of Healthy Connections. To report fraud, call our confidential Fraud Hotline at 877-725-2702. You may also call the South Carolina Department of Health and Human Services Fraud Hotline at 888-364-3224 or email [email protected]. BSCPEC-1018-18 September 2018 Healthy Blue Cymbalta (Duloxetine HCl) Prior Authorization of Benefits Form Page 2 of 3 Patient name: _______________________________________ Patient ID #: __________________________________ Generalized anxiety disorder: □ Yes □ No Patient has a diagnosis of generalized anxiety disorder. □ Yes □ No Has the patient been on Cymbalta (Duloxetine) in the past 180 days (medication samples/coupons/discount cards are excluded from consideration as a trial)? □ Yes □ No Has the patient had a trial (medication samples/coupons/discount cards are excluded from consideration as a trial) of and inadequate response or intolerance to one of the following medications: venlafaxine (immediate- or extended-release products), buspirone, escitalopram or paroxetine? Neuropathic pain associated with diabetic peripheral neuropathy: □ Yes □ No Patient has a diagnosis of neuropathic pain associated with diabetic peripheral neuropathy. □ Yes □ No Has the patient had a trial (medication samples/coupons/discount cards are excluded from consideration as a trial) of and inadequate response or intolerance to one of the following medications: a tricyclic antidepressant, gabapentin, venlafaxine (immediate- or extended-release products) or Lyrica? [Please note: Prior authorization (PA) may be required for Lyrica.] □ Yes □ No Has the patient had a previously approved clinical prior authorization review through Healthy Blue for Cymbalta (Duloxetine) in the past year that has recently expired? Fibromyalgia: □ Yes □ No Patient has a clinical diagnosis of Fibromyalgia (for example, based on symptoms of widespread pain, typically reported in the muscles and joints, findings of multiple tender points in characteristic soft tissue locations, and any disorder that would otherwise explain the pain have been excluded). □ Yes □ No Have the symptoms been present at a similar level for at least three months? □ Yes □ No Has the patient had a trial of and inadequate response or intolerance to two of the following medications that are FDA-approved or medically accepted for the treatment of fibromyalgia: a tricyclic antidepressant, gabapentin, cyclobenzaprine, fluoxetine or an alternative selective serotonin reuptake inhibitor, Savella, or Lyrica? [Please note: PA may be required for Savella and Lyrica.] □ Yes □ No Has the patient had a previously approved clinical PA review through Healthy Blue for Cymbalta (Duloxetine) in the past year that has recently expired? Chronic musculoskeletal pain: □ Yes □ No Patient has a diagnosis of chronic musculoskeletal pain (such as chronic low back pain or chronic pain from osteoarthritis). □ Yes □ No Has the patient had a trial (medication samples/coupons/discount cards are excluded from consideration as a trial) of and inadequate response or intolerance to one of the following medications: a nonsteroidal anti-inflammatory drug (individually or as part of a combination product), acetaminophen (individually or as part of a combination product) or tramadol? □ Yes □ No Has the patient had a previously approved clinical PA review through Healthy Blue for Cymbalta (Duloxetine) in the past year that has recently expired? Healthy Blue Cymbalta (Duloxetine HCl) Prior Authorization of Benefits Form Page 3 of 3 Patient name: ______________________________________ Patient ID #:__________________________________ 9. Physician signature ______________________________________________________ _______________________________________ Prescriber or authorized signature Date Prior authorization of benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what medications are appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations and exclusions. The submitting provider certifies that the information provided is true, accurate and complete and the requested services are medically indicated and necessary to the health of the patient. Note: Payment is subject to member eligibility. Authorization does not guarantee payment. THIS MESSAGE IS INTENDED ONLY FOR THE USE OF THE MEDICAL PROVIDER TO WHOM IT IS ADDRESSED AND MAY CONTAIN HEALTH INFORMATION THAT IS PROTECTED BY LAW. If this transmission contains the protected health information of an individual who is unknown to your practice, please notify us immediately by calling 866-757-8286. Please be advised that copying, sharing or any further use or disclosure of this communication is strictly prohibited. .