Prior authorization criteria for:
Cymbalta®
(duloxetine)
COVERED USES:
FDA Approved Indications:
- Diabetic peripheral neuropathic pain
- Fibromyalgia
- Generalized anxiety disorder
- Major depressive disorder
All FDA-approved indications not otherwise excluded from Part D.
AGE RESTRICTIONS:
NA
PRESCRIBER RESTRICTIONS:
NA
REQUIRED MEDICAL INFORMATION:
For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.
CRITERIA:
- Treatment of Diabetic Peripheral Neuropathic Pain; OR
- Trial and failure of two formulary antidepressants for the treatment of Major Depressive Disorder; OR
- Trial and failure of two formulary medications used in the treatment of anxiety excluding benzodiazepines; OR
- Treatment of fibromyalgia.
EXCLUSION CRITERIA:
NA
COVERAGE DURATION:
Initial authorization and reauthorization will be approved for up to one year.