Botox CCRD Prior Authorization Form - Cigna
antiepileptic drugs (divalproex, sodium valproate, topiramate) antidepressants (amitriptyline, venlafaxine) beta blockers (atenolol, metoprolol, nadolol, propranolol, timolol) none of the above Please include drug name and strength, date(s) taken and for how long, and what the documented results were of taking each drug checked.
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